W  fearning  anb  'guhox.  ^ 

J  LIBRARY  I 

I  Universityof  Illinois.  | 

^  Cr.ASS.               BOOK.  VOLUME.  ^ 


# 


Accession  No. 


ON 


THE  WASTING  DISEASES 


OF 


INFANTS  AND  CHILDREN 


BY 

EUSTACE  SMITH,  M.D. 

FELLOW  OF  THE   ROYAL  COLLEGE  OF  PHYSICIANS 
PHYSICIAN  TO  HIS    MAJESTY  THE  KING  OF   THE  BELGIANS 
SENIOR  PHYSICIAN  TO  THB  EAST   LONDON   CHILDREN'S    HOSPITAL  AND  TO   THE    CITY  OF  LONDON 
HOSPITAL  FOR  DISEASES  OF  THE  CHEST,  VICTORIA  PARK 


SIXTH  EDITION 


PHILADELPHIA 

P.  BLAZISTON'S  SON   &  CO. 
1012,  WALNUT  STREET 
1899 

PrirUed  in  Great  Britain 


PREFACE  TO  THE  SIXTH  EDITION. 


In  its  original  design  this  volume  was  not  intended  to 
be  a  manual  for  the  nursery  or  a  mere  treatise  on  the 
hand-feeding  of  infants.  The  aim  of  the  author  lay  far 
beyond  this.  It  was  his  object  to  set  forth  in  a  handy 
and  readable  shape  the  principal  forms  which  chronic 
interference  with  nutrition  may  take,  not  only  in  bottle- 
fed  infants,  but  also  in  older  children  up  to  the  age  of 
puberty ;  to  describe  these  ailments  from  a  clinical  stand- 
point ;  and  to  set  out  with  much  minuteness  the  methods 
by  which  they  might  be  remedied  and  health  restored.  In 
all  subsequent  editions  this  end  has  been  kept  in  view, 
and  each  new  issue  has  embodied  the  results  of  increased 
experience  in  the  treatment  of  these  complaints. 

The  last  edition,  the  fifth,  appeared  ten  years  ago,  and 
the  book  for  some  years  has  been  out  of  print.  The  delay 
in  re-publication,  which  has  been  much  complained  of,  has 
been  due  to  the  many  alterations  required  and  the  little 
time  at  the  author's  disposal  to  deal  with  them,  for  much 
of  the  pathology  was  out  of  date,  and  the  whole  required 
careful  revision.  In  the  present  issue  large  portions  of 
the  book  have  been  re-written,  and  a  chapter  has  been 
added  on  the  subject  of  subacute  tuberculosis  in  infants. 
But  many  other  changes  and  additions  have  been  made, 

66405 


vi 


PREFACE 


especially  in  the  pages  devoted  to  treatment ;  and  the 
author  now  ventures  to  hope  that  the  directions  given  as 
to  food,  medicine,  and  general  management  leave  little  to 
be  desired  for  clearness  and  fulness  of  detail. 

The  dietaries  in  the  last  chapter  have  also  been  revised. 
These  dietaries  were  a  new  feature  in  the  second  edition, 
which  appeared  in  the  year  1870.  It  was  the  first  attempt 
made  to  tabulate  the  meals  of  such  young  patients,  and 
its  usefulness  has  been  generally  acknowledged;  indeed, 
its  example  has  been  followed  by  most  of  the  manuals  on 
the  subject  of  children's  diseases  which  have  been  pub- 
lished in  recent  years. 

In  conclusion,  the  author  would  say  that  the  whole 
work  has  been  prepared  with  an  eye  to  the  needs  of  the 
young  medical  man  who  finds  his  practice  to  consist 
largely  of  cases  which  are  strange  to  him  from  the  mere 
age  of  the  patients — of  cases  which  his  previous  training 
amongst  adult  sufferers  has  little  qualified  him  to  treat 
with  success. 

15,  Queen  Anne  Street, 

Cavendish  Sqtjaee; 

June  oth^  1899. 


CONTENTS 

INTEODUCTION 

PAGE 

Wasting  a  sign  of  defective  nutrition         .              .  .  1 

Importance  of  deteeting  the  cause  of  mal-nutrition    .  .  2 

Wasting  not  always  the  first  sign,  and  may  even  be  absent  in 

slight  cases            .             .             .             .  .2 

Defective  nutrition  may  be  the  result  of  acute  disease  .  3 
Liability  of  badly  nourished  children  to  secondary  acute  diseases  3 

Peculiarities  of  these  secondary  diseases      .             .  .4 

Insensibility  of  the  nervous  system  in  cachectic  children  .  4 

Infrequency  of  reflex  convulsions             .             .  .4 

Importance  of  detecting  the  secondary  diseases        .  .  5 
Information  to  be  derived  from  examining  the  face  of  the  infant  5 

M.  Jadelot's  lines          .             .             .             ,  .6 

Colour  of  face             .             .             .             .  .7 

Breathing       .             .             .              .             .  .7 

Cry.              .              .              .              .              .  .7 

Causes  of  large  belly  in  infants    .             .             .  .8 

Infrequency  of  mesenteric  disease              .              .  .9 

Mode  of  examining  liver  and  spleen           .             .  .9 

General  treatment  of  wasting       .             .              .  .10 

Uselessness  of  tonics  so  long  as  there  remains  any  derangement 

of  the  stomach  and  bowels     .             .             .  .10 

Importance  of  minuteness  in  giving  directions  about  diet  .  10 

External  applications     .             .              .             .  .10 

Frictions        .             .             .              .             .  .10 

Anointing  with  warm  olive  oil      .             .              .  .11 

Counter-irritants           .              .             .             .  .12 

Baths— Hot  bath          .             .             .             .  .13 

Mustard  bath    .             .             .             .  .13 

Cold  bath         .             .             .             .  .13 


viii 


CONTENTS 


PAGE 

Internal  remedies         .  .  .  .  .15 

Cod-liver  oil  must  not  be  given  in  too  large  doses       .  .  15 

Stimulants     .  .  .  .  .  .15 


CHAPTEE  I 


Infantile  Atkophy. 

Causation       .             .             .             .  .  .17 

Insufficient  supply  of  food     .              .  .  .17 

Variations  in  breast-milk             .  .  .  17 

Test  of  a  good  nurse       .              .  .  ,17 

Unwise  feeding      .             .             .  .  .18 

Dependence  of  nutrition  upon  powers  of  digestion       .  18 

Varieties  of  food  required  for  perfect  nutrition  .  19 

Differences  between  woman's  and  cow's  milk  .  20 

Cow's  milk  cannot  always  be  digested  .  .  21 

Symptoms      .             .             .             .  .  .22 

Two  classes  according  to  cause             .  .  .22 

Food  suitable,  but  insufficient       .  .  .22 

Food  unsuitable             .             .  .  .23 

Wasting  .             .              .  .  .23 

Constipation            .              .  .  .23 

Cause  of  inactivity  of  bowels  .  .  24 

Ilatulence              .             .  .  .24 

Colic        .             .              .  .  .24 

Ravenous  appetite   .             .  .  .25 

Eruptions  on  skin    .             .  .  .25 

Thrush,  its  importance  in  prognosis      .  .  26 

Inward  fits             .             .  .  .27 

Attacks  of  vomiting  and  diarrhoea  .  .  27 

Aphthse    .              .             .  .  .28 

Nephritis  .              .             .  .  .29 

Otitis       .             .              .  •.  .29 

Treatment      .             .             .             .  .  .30 

Suckling  by  mother  or  nurse             .  .  .30 

Rules  for  choosing  nurse       .             .  .  .30 

Directions  for  efficient  suckling           .  .  .31 
Advantages  of  putting  child  early  to  breast  after  birth     .  32 

Times  of  suckling               .             .  .  .33 

Artificial  feeding    .             .             .  .  .34 


CONTENTS 


ix 


PAGE 

Sterilisation  of  milk             .  .  .  .35 

Methods  of  preparing  cow's  milk  .  .  .35 

"  Artificial  human  milk  "       .  .  .  .36 

Gartner's  milk       .             .  .  .  .36 

Milk  with  lime-water           .  .  .  .37 

Milk  with  barley-water         .  .  .  .37 

Milk  with  gelatine              .  .  .  .38 

Value  of  malt        .             .  .  .  .40 

Malted  foods         .             .  .  .  .40 

Pancreatised  foods  .              .  .  .  .40 

Milk  laboratories    .              .  .  .  .41 

Variety  in  feeding  .              .  .  .  .42 

Frequency  of  meals              .  .  .  .43 

Cleanliness  of  feeding-bottle  .  .  .  .43 

Cow's  milk  may  disagree       .  .  .  .43 

Various  milks  compared       .  .  .  .44 

Goat's  and  ass's  milk            .  .  .  .44 

Strippings "         .              .  .  .  .45 

Condensed  milk      .              .  .  .  .45 

Peptonised  milk     .              .  .  .  .46 

Modification  of  diet  in  case  of  gastric  catarrh      .  .    '  46 

Farinaceous  foods   .             .  .  •  .  .46 

Chapman's  wheat  flour          .  .  .  .48 

Baked  flour           .              .  .  .  .49 

Other  foods           .             .  .  .  .49 

Weaning               .             .  .  .  .50 

Usual  time      .             .  .  .  .51 

Must  sometimes  be  anticipated  .  .  .51 

Method  of  weaning       ,  .  .  .52 

Reasons  why  a  child  may  refuse  breast  .  .  52 

Diet  after  weaning             .  .  .  .54 

General  management  of  infants  .  .  .55 

Use  of  soap  in  the  nursery    .  .  .  .55 

Treatment  of  constipation     .  .  .  .56 

Flatulence  and  acidity  .  .  .58 

Screaming  fits  .  .  .  .61 

Convulsions  and  colic  .  .  .62 

Thrush           .  .  .  .63 

Aphtha           .  .  .  .64 

Diarrhoea  and  vomiting  .  .  .64 


X 


CONTENTS 


CHAPTER  II 

PAG?: 

ClIKONIC  DiAREHCEA  (ChEONIC  INTESTINAL  CaTAEEH). 


May  be  secondary  to  acute  disease  .  .  .66 

Or  may  be  primary               .  .  ,  .67 

Mode  of  beginning  when  primary  .  .  .67 

When  disease  established       .  .  .  .68 

Character  of  the  stools         .  .  .  .68 

Other  symptoms     .              .  .           '   .  .69 

Complications               .              .  ,  .  .70 

Serous  effusions             .  .  .  .70 

Pneumonia      .              .  .  .  .70 

Exanthemata  .              .  .  .  .70 

Convulsions      .              .  .  .  .70 

Thrombosis  of  cerebral  sinuses  .  .  .71 

Death  without  complication   .  .  .  .72 

Diarrhoea  may  cease  before  death  .  .  .72 

Influence  of  the  disease  upon  dentition  .  .  73 

Diarrhoea  in  older  children    .  .  .  .74 

Lienteric  diarrhoea                .  .  .  .75 

Causation — In  infants,  bad  hygiene  .  .  .76 

cold          .  .  .  .78 

previous  acute  disease  .  .  79 

In  older  children,  worms  .  .  .79 

tubercular  ulceration  of  bowels  .  80 

Morbid  anatomy           .              .  .  .  .80 

Simple  ulceration  of  mucous  membrane  .  .  80 

Tubercular  or  scrofulous  ulceration  .  .  .81 

Diagnosis       .             .             .  .  .  .82 

Prognosis — Unfavourable  signs    .  .  .  .85 

Favourable  signs        .  .  .  .85 

Preveiition      .              .              .  ,  .  .85 

Attention  to  diet     .     ,        .  .  .  .86 

Avoidance  of  cold    .              .  .  .  .87 

Influence  of  dentition            .  .  .  .87 

Treatment — In  infants  .              .  ,  .  .88 

General  management            .  .  .  .88 

Washing  bath  forbidden        .  .  .  .89 

Diet        .             .              .  .  .  .90 

External  applications            .  .  .  .95 

Internal  remedies   .             .  .  .  .96 


CONTENTS  Xi 

PAGE 

Malt  extract  .  .  .  .  .97 

Finkler's  papain     .  .  .  .  .97 

Antacids  .  .  .  .  .  .98 

Astringents  .  .  .  .  .99 

Nitrate  of  silver     .  .  .  .  .99 

Perchloride  of  mercury         ....  100 

Raw  meat  .....  100 

Tonics     .  .  .  .  .  .101 

In  older  children    .....  102 

Treatment  of  lienteric  diarrlicea  .  .  .  103 

Illustrative  cases    .  .  .  .  .  103 

CHAPTEE  III 
Cheonic  Vomiting  (Cheonic  Gasteic  Cataeeh). 

Frequency  of  slight  attacks  of  gastric  disturbance  .  105 

Such  attacks  easily  remedied  ....  105 

Chronic  vomiting  non-febrile  .  .  .  105 

Symjptoms      .  .  .  .  .  .105 

Character  of  vomited  matters  .  .  .  105 

Constipation  .....  106 

Interference  with  nutrition   .  .  .  .  106 

After  a  time  vomiting  almost  constant .  .  .  106 

Exhaustion  .....  107 

Spurious  hydrocephalus         ....  107 

Causation       .  .  .  .  .  .108 

Diagnosis       .  .  .  .  .  .110 

From  tubercular  meningitis  ....  110 

Treatment      .  .  .  .  .  .110 

Warmth  .  .  .  .  .  .110 

Attention  to  diet    .....  Ill 

Return  to  breast    .....  112 

Substitute  for  wet-nurse       .  .  .  .112 

Exclusion  of  milk  from  diet  .  .  .  .  113 

White  wine  whey   .  .  .  .  .  113 

Medicines  .....  116 

Arsenic    ......  116 

Cocain     ......  116 

Calomel  in  small  doses  .  .  .  .117 

Stimulants  .....  117 

Value  of  emetics    .  ,  .  .  .117 

Treatment  of  spurious  hydrocephalus   .  .  .118 

After-treatment     .  .  .  .  .  118 


xii 


CONTENTS 


CHAPTER  IV 

PAGE 

KiCKETS 

Preliminary  symptoms  those  of  general  malnutrition         .  120 
Symptoms  of  beginning        ....  121 

Deformities  of  bone  ....  123 

Bones  of  skull  and  face         .  .  .  .124 

Distinction  between  rickety  and  hydrocephalic  skull  .  125 

Cranio-tabes  .....  126 

Dentition  .....  126 

Teeth  sometimes  unaffected  ....  127 

Illustrative  case     .....  127 

Spine      .  .  .  .  .  .127 

Thorax    .  .  .  .  .  .128 

Deformities  of  pelvis  ....  131 

Arrest  of  growth  of  bones     ....  133 

Articulations         .....  134 

Kelaxation  of  ligaments        ,  .  .  .135 

Other  symptoms     .....  135 

Enlargement  of  liver  and  spleen  .  .  .  137 

Intellect  .  .  .  .  .  .137 

General  behaviour  of  a  rickety  child     .  .  .  137 

Complications        .....  138 

Catarrh  and  bronchitis   ....  138 

Diarrhoea        .  .  .  .  .139 

Laryngismus  stridulus   ....  140 

Convulsions     .....  140 

Chronic  hydrocephalus  ....  142 

Scurvy  .....  143 

Cause  of  death       .....  145 

Favourable  termination         ....  145 

Resumption  of  dentition       ....  145 

Fathology      .  .  .  .  .  '   .  147 

Rickets  a  general  disease       .  .  .  .  147 

Microbic  theory      .  .  .  .  .148 

Morbid  anatomy     .  .  .  •  .149 

Ossification  per  verted  .  .  .  .149 

Reconsolidation  of  rickety  bone  .  .  .  150 

Analysis  of  rickety  bone       ....  151 

Emphysema  and  collapse       .  .  .  •  152 

Alterations  in  liver  .  .  .  •  153 

spleen  .  .  .  .154 

other  organs    ....  155 


CONTENTS  Xiii 

PAGE 

Urine      ......  155 

Rickets  and  osteomalacia      ....  156 

Diagnosis      ......  156 

Prognosis      ......  159 

Importance  of  complications  .  .  .  159 

Causation      ......  160 

Rickets  not  a  diathetic  disease  .  .  .  160 

Bad  feeding  and  insanitary  conditions  .  .  163 

Connection  between  rickets  and  syphilis  .  .  164 

Prevention     .  .  .  .  .  .164 

Treatment     ......  165 

Attention  to  digestive  organs  .  .  .  165 

Diet       .  .  .  .  .  .166 

Dry  bracing  air      .  .  .  .  .  167 

Warmth  .  .  .  .  .  .168 

Cleanliness  .....  168 

Tonics     .  .  .  .  .  .168 

Cod-liver  oil  ....  .  169 

Value  of  mechanical  supports  .  .  .  170 

Treatment  of  complications  ....  171 

Catarrh  .  .  .    •  .  .171 

Diarrhoea        .....  172 

Convulsions     .....  174 

Laryngismus  stridulus   ....  175 

Scurvy  .  .  .  .  .176 

CHAPTER  V 

Inherited  Syphilis. 

Appearance  of  first  symptoms  .  .  .  177 

Before  birth    .  .  .  .  .177 

At  birth         .  .  .  .  .177 

Afterbirth     .  .  .  .  .178 

Fretfulness  at  night  .  .  .  .178 

Snuffling  .  .  .  .  .  .179 

Necrosis  of  nasal  bones        ....  180 

Eruptions  .....  180 

Seat       .  .  .  .  .  .180 

Varieties ......  180 

Ecthymatous  pustules  ....  181 

Mucous  patches      .....  181 

Cracks  and  fissures .....  182 


xiv 


CONTENTS 


PAGE 

Complexion  .....  182 

Cry         .....  .  182 

Openness  of  fontanelle         ....  183 

Disease  of  bones    .  .  .  .  .183 

Separation  of  epiphyses        ....  183 

Nodes     .  •  .  .  .  .184 

Enlargement  of  glands         ....  184 

Enlargement  of  spleen         ....  184 

General  cachexia    .....  185 

Paralysis  ......  185 

Delayed  symptoms  .....  186 

Relapses  .....  .  187 

Morbid  anatomy  .  .  .  .  .188 

Changes  in  the  bones  ....  188 

In  bones  of  skull  .....  190 
Cranio-tabes  .....  190 

Syphilitic  dactylitis  ....  191 

Disease  of  mucous  membrane  .  .  .  191 

Internal  organs     ....  192 
Lungs  ....  192 

Liver  ....  192 

Spleen  .  .  .  .194 

Heart  .  .  .  .194 

Kidneys  ....  194 
Supra-renal  capsules      .  .  .  194 

Diagnosis       .  .  .  .  .  .194 

By  general  symptoms  ....  194 

Value  of  individual  symptoms  .  .  .  195 

By  examination  of  other  children  of  the  same  family  .  196 
Signs  of  past  disease  in  child  .  .  .  19G 

Causation      ......  196 

Transmission  of  taint  from  father       .  .  .  197 

Transmission  of  taint  from  mother      .  .  .  198 

Twins  not  always  equally  affected        .  .  .  199 

Other  modes  of  infection       ....  200 

Prognosis       .  .  .  .  .  .  200 

Importance  of  considering  the  intensity  of  the  general 

cachexia  .....  201 

Importance  of  certain  special  symptoms  .  .  201 

Prevention     ......  202 

Treatment      ......  202 

Two  objects  .  .  .  .  .202 

Treatment  to  be  begun  early  .  .  .  203 


CONTENTS  XV 

PAGE 

Mercurial  preparations   ....  203 

External  applications     ....  204 

Ointment        .  .  .  .  .204 

Mercurial  baths  ....  205 

To  improve  general  nutrition  .  .  .  205 

Diet       .  .  .  .  .  .205 

Cod-liver  oil  .  .  .  .  .206 

Warmth  .  .  .  .  .  .206 

Cleanliness  .....  206 

Treatment  of  vomiting  and  diarrhoea  .  .  .  207 

Local  applications  .....  208 

Tonics     .  .  .  .  .  .209 


CHAPTEE  VI 

Mucous  Disease. 

Character  of  the  derangement            .  .          .             .  210 

Symptoms      ......  210 

Nightmare  .  .  ...  .210 

Somnambulism       .  .  .  .  .211 

Incontinence  of  urine           ....  211 

Nervous  restlessness             ....  211 

Appearance  of  tongue  .  .  .  .211 

Bowels    ......  212 

Foetor  of  breath     .....  212 

Complexion           .....  213 

Abdominal  pains     .             .              .             .             .  213 

Dry  rough  skin      .....  213 

Temperature          .....  214 

Bilious  attacks       .....  214 

Worms  a  common  complication            .              .             .  214 

Explanation  of  the  symptoms             .              .              .  215 

Causation       .....              .  216 

Influence  of  previous  diseases             .             .             .  216 

Whooping-cough            ....  216 

Susceptibility  to  chill        ....  217 

Second  dentition               ....  217 

Diagnosis      ......  218 

From  tuberculosis  .....  218 


xvi 


CONTENTS 


PAGE 

Treatment      .  .  .  .  .  .219 

Diet        .  .  .  .  .  .219 

Exclusion  of  starchy  food     ....  219 

A  dietary  .....  220 

Allowed  vegetables  ....  220 

Alcohol    ......  220 

Restore  action  of  skin  ....  221 

Warm  clothing      .....  221 

Internal  remedies   .....  222 

Alkalies  ......  222 

Aloes       ......  222 

Iron        .  .  .  .  .  .223 

Purgatives  .....  224 

Case  illustrating  treatment    .  .  .  .  224 

Acids       .  .  .  .  .  ,225 

Cod-liver  oil  .  .  .  .  .  226 

Change  of  air        .  .  .  .  .  226 

CHAPTER  VII 

Worms. 

Varieties       .  .  .  .  .  .  227 

Description    ......  227 

Oxyuris  vermicularis  ....  227 

Ascaris  lumbricoides  ....  228 

Tricocephalus  dispar  .  .  *  .  228 

Taenia  solium         .....  229 

Tsenia-medio  canellata  ....  230 

Bothriocephalus  latus  ....  230 

Mode  of  obtaining  admission  into  human  body   .  .  231 

Symptoms      .  .  .  .  .  .233 

Due  principally  to  accompanying  derangement  of  stomach 

and  bowels      .  .  .  .  .233 

Emaciation  .....  234 

Pain       .  .  .  .  .  .234 

Disturbance  of  nervous  system  .  .  .  235 

Convulsions  .....  235 

Special  symptoms  with  each  variety  of  worms    .  .  235 

Diagnosis      .  .  .  .  .  .238 

From  tuberculosis  .....  239 

From  tubercular  meuingitis  ....  240 


CONTENTS                           ^  Xvii 

PAGE 

Treatment      .             .             .             .             .             .  240 

Two  objects           .....  240 

To  expel  worms             ....  240 

Remedies  required  for  each  variety             .             .  240 

Thread-worms         ....  240 

Long  worms           ....  241 

Large  thread-worms             .             .             .  241 

Tape-worms           ....  244 

To  restore  healthy  condition  of  alimentary  canal        .  247 

Treatment  of  prolapsus  ani          .             ,             .  247 

CHAPTEE  VIII 

Tuberculosis. 

The  tubercle  bacillus            ....  249 

Mode  of  entrance  into  the  body           .             .             .  250 

By  the  alimentary  canal        ....  250 

By  the  air  passages.             ....  250 

By  the  tonsils        .             .             .    •         .             .  250 

Infection  of  lymphatic  glands             .             .             .  251 

The  "  tuberculous  diathesis  " .             .             .             .  251 

The  "  strumous "  type          ....  252 

Resisting  power  of  the  system             .             .              .  253 

Varieties  of  tuberculosis        ....  254 

General  Subacute  Tuberculosis  oe  Infants. 

Fathology      ......  254 

Symptoms      ......  255 

Interference  with  nutrition  ....  255 

Local  symptoms  rare           ....  256 

Temperature          .....  256 

Mode  of  ending      .....  257 

Diagnosis      ......  257 

Prom  inherited  syphilis         ....  259 

CHAPTEE  IX 
Tuberculosis  of  the  Lungs. 

Pathology      .  .  .  .  .  .261 

Mode  of  entrance  of  microbes             •             .             .  262 

Symptoms      ......  263 

Varieties  of  shape  of  chest    ....  264 


h 


xviii 


CONTENTS 


PAGE 

The  alar  or  pterygoid  chest  ....  264 

The  flat  chest        .....  264 

The  pigeon-breasted  chest     ....  264 

Chronic  Pulmonary  Tuberculosis. 

General  symptoms  .....  265 

Wasting  .  .  .  .  .  .265 

Cough     ......  265 

Haemoptysis           .....  266 

Rapid  breathing     .....  267 

Chest  pains           .....  267 

Appetite  ......  267 

Diarrhoea              .....  268 

Influence  of  pyrexia             ....  269 

Mode  of  death        .  .  .  .  ,269 

Course  of  primary  chronic  tubercular  phthisis     .             .  269 

Course  of  pneumonic  phthisis              .             .              .  270 

Symptoms  of  softening  of  deposit        .             .              .  270 

Slow  development  of  pneumonic  phthisis           .             .  271 

Secondary  acute  tuberculosis ....  271 

Fibroid  induration  of  lung    ....  271 

Character  of  cough              ....  272 

Absence  of  pyrexia               ....  272 

Enlargement  of  liver  and  spleen          .             .             .  273 

Physical  signs              .....  273 

Examination  of  chest  in  a  child           .             .             .  273 

Peculiarities  of  physical  signs             .              .             .  273 

Percussion  of  the  chest         .             .  -           .             .  273 

Auscultation          .....  275 

Bronchial  and  hollow  breathing           .             .             .  275 

Conduction  of  sounds  by  enlarged  glands           .             .  275 

Eeeble  breath- sounds           ....  277 

Value  of  cavernous  breathing             .             .             .  277 

Physical  signs  in  chronic  tubercular  phthisis      .             .  277 

In  pneumonic  phthisis   ....  278 

In  fibroid  induration  of  lung        .             .             .  280 

CHAPTEE  X 

Cheonic  Pulmonary  Tuberculosis  (continued). 

Diagnosis       .....             .  282 

Of  chronic  primary  tubercular  phthisis              .             .  282 


CONTENTS 


xix 


PAGE 

Of  tubercular  phthisis  complicated  with  catarrhal  pneumonia  284 
Of  pneumonic  phthisis  .  .  .  .  284 

Sudden  onset  .  .  ,  .  .  284 

Insidious  beginning        ....  286 

Of  fibroid  induration  of  lung.  .  .  .  287 

Of  pulmonary  cavities  ....  288 

From  empyema  ....  288 

From  dilated  bronchi      ....  289 

Of  fibroid  phthisis  .  .  .  .  .289 

Prognosis       ......  290 

Prevention     ......  293 

Diet        .  .  .  .  .  .293 

Fresh  air .  .  .  .  .  .  294 

Dress      .  .  .  .  .  .  294 

Exercise  ......  294 

Residence  .  .  .  .  .  295 

Treatment     ......  296 

Climate   .  .  .  .  .  .297 

Air  and  exercise     .  .  .  •    .  .  297 

Diet       .  .  .  .  .  .299 

Attention  to  digestive  organs  .  .  .  300 

Cod-liver  oil  and  tonics         .  .  .  .  301 

Special  treatment   .....  302 

Expectorants   .....  303 

Antiseptic  inhalations     ....  304 

Counter-irritation  ....  305 

Arsenic  ....  305 

Belladonna     .  .  .  .  .305 

Treatment  of  cirrhosis  of  lung     .  .  .  305 


CHAPTEE  XI 

Tuberculosis  of  Lymphatic  Glands. 

Consequences  vary  according  to  seat    .             .             .  307 

Often  a  local  disease             ....  307 

Appearance  of  diseased  glands            .             .             .  308 

Further  changes     .....  308 
Softening       .             .             .             .  .308 

Petrifaction    .....  308 


XX 


CONTENTS 


PAGE 

Resolution  and  absorption  .  .  .  308 

Fibroid  change  ....  308 

Danger  from  softened  glands  .  ,  .  309 

Tuberculosis  of  Bronchial  Glands     .  .  .  .  309 

Seat        .  .  .  .  .  .309 

Symptoms      ......  310 

General   ......  310 

Frequency  of  catarrhs  .  .  .  .310 

Special    ......  311 

Pressure  on  veins    .....  311 

Pressure  on  nerves  .  .  .  .  .311 

Cough  ....  .  312 

Altered  voice  .....  312 

Dyspnoea        .....  312 

Physical  signs  .  .  .  .  .  313 

Percussion  note  .....  313 
The  result  of  pressure  ....  313 

Auscultatory  signs  .....  313 
Complication  with  pulmonary  phthisis  .  .  .  314 

Modes  of  termination  ....  314 

Diagnosis      ......  314 

Earliest  diagnostic  sign         ....  315 

Illustrative  cases    .....  316 

Prognosis       ......  318 

Tuberculosis  oe  Mesenteric  Glands    .  .  .  319 

Symptoms      .  .  .  .  .  .319 

General   .  .  .  .  .  .319 

Local      .  .  .  .  .  .  320 

Pressure  on  veins    .....  321 

Ascites  rare  .....  321 

Modes  of  termination  ....  322 

Diagnosis       .  .  .  .       »      .  .  322 

From  fsecal  accumulation  ....  322 
From  tuberculous  masses  attached  to  the  omentum  .  323 

Existence  of  complications     ....  324 

Prognosis      .  .  .  .  .  .325 

Treatment     ......  326 

General  ......  326 

Special    .  .  .  .  .  .327 

Of  tuberculous  bronchial  glands    .  .  .  328 

Of  tuberculous  inesenteric  glands  .  •  .  329 


CONTENTS 


xxi 


CHAPTEE  XII 
Diet  of  Childeen  in  Health  and  Disease. 


Diet  in  health              .....  331 

Vvoxn  birth  to  six  months  old.             .              .             .  331 

From  six  to  twelve  months  old            .              .             .  334 

From  twelve  to  eighteen  months  old     .              .              .  337 

From  eighteen  months  to  two  years  old             .             .  339 

After  two  years      .....  340 

Diet  in  disease              .             .             .     '        .             .  340 

In  simple  atrophy  .....  340 

In  chronic  diarrhoea             ....  342 

In  chronic  vomiting             ....  345 

In  rickets             .....  346 

In  raucous  disease  .  .  .  .  .  347 
In  pulmonary  phthisis          .             .             .  .350 


C 


OJSl  THE 

WASTING  DISEASES  OF  INFANTS 
AND  CHILDIIEN 


INTRODUCTION 

WASTINGr  is  a  sign  of  defective  nutrition  ;  the  waste 
of  the  body  continues,  but  new  material  is  intro- 
duced in  quantity  insufficient  to  supply  the  loss  of  tissue. 

Wasting  may  be  temporary  or  persistent.  Every  devia- 
tion from  health  will  affect,  to  a  certain  extent,  the 
nutrition  of  the  body,  and,  according  as  the  interference 
with  nutrition  is  more  or  less  complete,  the  wasting  goes 
on  with  more  or  less  rapidity.  The  interference  is  great 
in  proportion  to  the  acuteness  of  the  cause  which  pro- 
duces it.  Any  acute  disorder,  such  as  an  inflammatory 
attack  or  an  attack  of  acute  diarrhoea,  will  produce  an 
immediate  pause  in  the  nutritive  process :  the  flesh  at 
once  begins  to  feel  flabby  and  soft ;  and  a  continuance  of 
the  purging,  if  the  drain  be  severe,  causes  a  visible  loss  of 
flesh,  which  is  as  rapid  as  it  is  alarming.  On  the  cessa- 
tion of  the  acute  attack,  the  flesh  is  recovered  almost  as 
rapidly  as  it  was  lost:  a  few  days  restore  the  child's 

1 


2 


INTRODUCTION 


ordinary  appearance,  and  with  his  flesh  his  colour  and 
spirits  return.  On  the  other  hand,  in  chronic  disorders, 
emaciation  proceeds  much  more  gradually ;  but  nutrition, 
as  it  is  slowly  impaired,  is  also  slow  to  be  re-established. 
The  present  volume  deals  only  with  cases  of  slow  impair- 
ment of  nutrition,  where  the  loss  of  flesh  is  gradual,  and 
the  wasting  cannot  be  attributed,  at  any  rate  directly, 
to  any  acute  febrile  attack.  In  all  such  cases  the  cause 
should  be  carefully  inquired  for,  as  the  defect  in  nutrition 
can  only  be  effectually  remedied  by  removing  the  cause 
which  has  produced  it.  This  cause  may  be  unsuitable 
food,  the  child  being  actually  starving  from  his  inability 
to  digest  and  assimilate  the  diet  with  which  he  is  sup- 
plied. He  may  be  prevented  from  assimilating  an  ordi- 
narily digestible  diet  by  some  unhealthy  condition  of  his 
alimentary  canal ;  or  a  constitutional  defect,  such  as  the 
existence  of  tuberculosis,  or  the  poison  of  syphilis  per- 
vading the  system,  may  interfere  with  the  proper  nutrition 
of  the  tissues. 

It  is  extremely  important  to  detect  the  earliest  symptoms 
of  defective  nutrition.  Wasting  is  not  always  one  of  the 
first  signs,  and  may  even  be  altogether  absent  if  the  inter- 
ference with  nutrition  is  not  carried  to  a  high  degree. 
Thus,  a  child  may  be  exceedingly  plump,  and  may  perhaps 
excite  admiration  by  his  good  condition,  although  at 
the  same  time  he  be  suffering  from  the  insidious  com- 
mencement of  rickets,  which,  if  the  causes  producing  the 
disease  continue  unchecked,  will  shortly  assert  itself  un- 
mistakably. Acute  disease  is  often  a  starting-point  for 
mal-nutrition,  either  by  awakening  a  dormant  diathetic 
tendency ;  or  by  leaving  behind  it  a  chronic  derangement 
of  the  alimentary  canal;  or  by  impeding  nutrition  by 
some  mysterions  influence  over  nervous  power.  Thus 
measles  not  unfrequeiitly  excites  the  manifestations  of  a 
previously  latent  tubercular  tendency  ;  scarlatina  and 
measles  are  apt  to  be  followed  by  obstinate  diarrhoea, 


INTRODUCTION 


3 


and  diphtheria  is  often  succeeded  by  a  loss  of  nervous 
power,  usually  indeed  local,  but  sometimes  general  and 
sufficiently  serious  to  interfere  with  the  working  of  all  the 
functions  of  the  body. 

In  every  acute  disease  there  are,  therefore,  two  dangers ; 
the  immediate  danger  and  the  remote  danger.  The  first 
presses  itself  upon  our  notice,  and  cannot  be  overlooked ; 
the  second,  obscured  by  distance,  is  apt  to  be  disregarded. 
Acute  disease  always  excites  attention  and  receives  imme- 
diate treatment,  but  it  is  not  enough  to  rest  satisfied  with 
the  cessation  of  pressing  symptoms.  There  is  always  the 
danger  that  the  defective  nutrition,  at  first  merely  tempo- 
rary, may  become  confirmed ;  in  other  words,  that  chronic 
disease  may  be  established. 

One  consequence  of  the  weakly  condition  to  which  badly 
nourished  children  are  reduced  is  their  liability  to  second- 
ary acute  diseases.  In  a  child  sulfering  from  the  results 
of  chronic  interference  with  nutrition,  from  whatever 
cause,  the  power  of  resisting  new  injurious  influences  is 
very  much  impaired.  In  such  a  state  he  is  constantly 
found  to  be  affected  by  causes  so  slight  as  to  pass  almost 
unnoticed,  and  which  in  a  healthy  child  would  be  com- 
pletely powerless  to  do  harm.  If  the  emaciation  and 
debility  of  the  child  are  very  great,  the  secondary  diseases 
may  give  very  little  evidence  of  their  presence  ;  for  an 
infant  reduced  by  mal-nutrition  to  a  cachectic  state  loses 
many  of  the  vital  characteristics  of  early  childhood,  espe- 
cially the  intense  excitability  of  the  nervous  system,  which 
is  so  striking  a  peculiarity  of  healthy  infancy.  In  a  robust 
child  we  constantly  find  the  whole  system  suffering  vio- 
lently from  sympathetic  derangement  set  up  by  some 
trifling  disturbance.  A  lump  of  indigestible  food,  or  a 
slight  impression  of  cold,  will  not  unfrequently  produce 
burning  fever,  and  alarming  nervous  symptoms,  as  deli- 
rium, convulsions,  or  even  a  state  approaching  to  coma. 
On  the  other  hand,  in  an  infant  much  reduced  by  long- 


4 


INTRODUCTION 


continued  impairment  of  nutrition,  the  most  serious  dis- 
eases may  give  no  signs  of  their  presence.  Pneumonia 
may  exist  with  little  fever  and  no  cough,  and  a  serious 
intestinal  lesion  without  pain  and  with  only  trifling  diar- 
rhoea. 

A  good  example  of  the  insensibility  of  the  nervous 
system  to  local  impressions  is  seen  by  attempting  the 
well-known  experiment  of  gently  simulating  the  genito- 
crural  nerve.  In  a  healthy  child  the  finger-nail  drawn 
lightly  along  the  upper  two  thirds  of  the  inner  aspect  of 
the  thigh  produces  an  instantaneous  rise  of  the  testicle  of 
that  side,  by  the  action  of  the  cremaster  muscle  which 
draws  it  up  close  to  the  external  abdominal  ring.  In  a 
cachectic  child  the  same  experiment  is  followed  by  no 
result  whatever ;  the  cremaster  does  not  contract,  and  the 
testicle  remains  motionless.  In  such  cases,  therefore,  there 
is  absence  of  the  normal  excitability  of  the  nervous  system 
so  characteristic  of  healthy  infancy.  This  insensibility  of 
the  parts  of  the  nervous  system  concerned  in  the  produc- 
tion of  reflex  movements  is  further  indicated  by  the  infre- 
quency  of  reflex  convulsions  in  such  children.  In  well- 
nourished  children  these  are  exceedingly  common,  and  the 
natural  nervous  sensibility  appears  to  be  heightened  by 
anything  which  causes  a  sudden  weakening  of  the  system, 
as  severe  acute  diarrhoea,  or  great  loss  of  blood.  When, 
however,  the  debility  is  produced  more  slowly,  the  same 
result  does  not  follow,  and  the  excitability  of  the  nervous 
system,  instead  of  being  exalted,  is  more  or  less  completely 
destroyed. 

For  this  reason,  acute  diseases,  attacking  a  child  whose 
nutrition  is  thus  seriously  impaired,  have  very  special 
features.  They  are  distinguished  by  an  absence  of  those 
peculiarities  which  we  are  accustomed  to  consider  insepa- 
rable from  the  disorders  of  childhood,  and  resemble  more 
the  same  diseases  as  they  occur  in  advanced  age.  They 
begin  more  insidiously ;  run  their  course  more  slowly ; 


INTRODUCTION 


5 


give  rise  to  fewer  symptoms  ;  and  often  end  suddenly  and 
unexpectedly  in  death.  Although  thus  undemonstrative, 
they  are  not,  however,  on  that  account  less  dangerous ; 
indeed,  the  prognosis  may  be  said  to  be  serious  in  pro- 
portion to  the  fewness  of  the  symptoms  by  which  their 
existence  is  announced.  By  offering  an  additional  obstacle 
to  nutrition  they  still  further  weaken  the  already  enfeebled 
constitution,  and  the  disease,  if  it  does  not  prove  imme- 
diately fatal,  is  apt  to  hang  on,  gradually  reducing  the 
child  more  and  more,  until  he  sinks  under  its  effects. 

It  is  difficult  to  over-estimate  the  importance  of  an  early 
diagnosis  of  these  secondary  disorders.  On  account  of 
their  insidious  beginning  they  are  frequently  overlooked, 
and  it  is  often  only  by  the  more  rapid  debility  they  induce 
that  suspicions  of  their  existence  are  at  last  excited.  As 
the  infant  is  unable  to  communicate  his  ideas  by  speech, 
the  eye  should  be  practised  to  gather  from  the  expression 
and  gestures  of  the  child  the  information  which  he  can 
give  in  no  other  way.  A  careful  perusal  of  the  face  is 
therefore  of  the  utmost  importance.  By  it  we  can  ascer- 
tain the  existence  of  pain,  and  can  often  distinguish  the 
part  of  the  body  which  is  the  seat  of  serious  disease. 
Thus,  pain  in  the  head  is  indicated  by  contraction  of  the 
brows  ;  in  the  chest,  by  a  sharpness  of  the  nostrils  ;  and 
in  the  belly,  by  a  drawing  of  the  upper  lip. 

M.  Jadelot,  a  former  physician  to  the  Hopital  des  Enfans 
Trouves  at  Paris,  was  the  first  to  draw  attention  to  certain 
lines  or  furrows,  which  become  marked  on  the  face  of  a 
child  suffering  from  serious  disease,  and  the  situation  of 
which  furnishes  indications  as  to  the  part  of  the  body  to 
which  it  is  necessary  to  direct  our  examination. 

The  oculo-zygo7natic  line,  or  furrow,  begins  at  the  inner 
angle  of  the  eye,  and  passing  outward  underneath  the 
lower  lid,  is  lost  a  little  below  the  projection  formed  by 
the  cheek-bone.  This,  points  to  disorder  of  the  cerebro- 
nervous  system,  becoming  strongly  marked  in  all  those 


6 


INTRODUCTION 


diseases  whose  j^rimary  seat  is  the  brain  or  nerves,  or  in 
cases  where  those  organs  become  affected  secondarily  to 
disease  which  has  begun  in  other  parts. 

The  nasal  line  rises  at  the  upper  part  of  the  ala  of  the 
nose,  and,  passing  downwards,  forms  a  rough  semicircle 
round  the  corner  of  the  mouth.  Joining  this  at  an  angle 
about  its  middle  is  another  line,  called  cjenal,  which  reaches 
from  that  point  almost  to  the  malar  bone,  and  in  certain 
faces  forms  the  dimple  of  the  cheek.  These  indicate  dis- 
eases of  the  digestive  passages  and  the  abdominal  viscera. 

The  lahial  line  begins  at  the  angle  of  the  mouth,  and  is 
directed  outwards,  to  be  lost  in  the  lower  part  of  the  face. 
It  is  seldom  so  deep  as  the  preceding.  It  is  a  sign  of 
disease  of  the  lungs  and  air-passages. 

M.  Jadelot  attributed  immense  importance  to  these  lines, 
and  even  stated  that  he  had  been  enabled  to  discover  the 
exact  period  at  which  the  cough  of  pertussis  assumed  its 
convulsive  character  by  the  a23pearance  of  the  oculo-zygo- 
matic  line  upon  the  child's  face.  Without,  however, 
attaching  to  them  the  same  significance  which  they  assumed 
in  the  opinion  of  their  discoverer,  there  is  no  doubt  that 
they  often  furnish  important  indications,  and  are,  there- 
fore, points  to  which  attention  should  always  be  directed 
in  the  examination  of  a  young  child. 

The  colour  of  the  face  should  be  carefully  noted.  Livi- 
dity  of  the  lips  and  of  the  eyelids,  if  extreme,  is  a  sign  of 
imperfect  aeration  of  the  blood ;  but  a  faint  purple  tint  of 
the  eyelids  and  round  the  mouth  usually  indicates  nothing 
more  than  weak  circulation,  or  a  slight  difficulty  of  diges- 
tion. *  A  peculiar  waxy-yellow  tint  is  seen  in  certain  parts 
of  the  face  in  inherited  syphilis ;  and  there  is  an  earthy 
tinge  of  the  face  and  whole  body  in  many  cases  of  chronic 
bowel  complaint.  Exhaustion  is  indicated  by  coolness  and 
pallor  of  the  face,  by  marked  lividity  of  the  eyelids  and 
mouth,  and,  in  extreme  cases,  by  a  half-closure  of  the  eyes, 
so  as  to  leave  the  lower  part  of  the  whites  exposed,  while 


INTRODUCTION 


7 


at  the  same  time  the  fontanelle  is  deeply  depressed.  The 
state  of  the  fontanelle  should  be  always  examined,  for  it 
forms  a  very  important  guide  to  treatment :  if  much  de- 
pressed, stimulants  should  never  be  withheld. 

The  breathing  must  be  watched.  If  rapid  and  accom- 
panied by  movement  of  the  nares,  there  is  usually  bron- 
chitis or  pneumonia,  and  a  careful  examination  of  the  chesf 
should  always  be  made.  Unequal  movement  of  the  two 
sides  of  the  chest  in  respiration  generally  indicates  a 
serious  lesion  on  the  side  at  which  the  movement  is  least. 
If  the  respiratory  action  of  the  abdominal  muscles  be  in- 
creased, attention  is  at  once  directed  to  the  chest.  If  the 
belly  be  motionless,  it  is  often  the  seat  of  an  inflammatory 
complication. 

The  cry  of  the  infant  varies  very  much  in  character. 
In  cerebral  affections  it  is  sharp,  short,  and  sudden.  In 
lesions  of  the  abdomen,  exciting  pain,  it  is  prolonged. 
In  inherited  syphilis,  it  is  high-pitched  and  hoarse.  In 
inflammatory  diseases  of  the  larynx  it  is  hoarse,  and  may 
be  whispering.  In  inflammatory  diseases  of  the  lungs, 
and  in  severe  rickets,  the  child  is  usually  quiet,  and  un- 
willing to  cry  on  account  of  the  action  interfering  with  the 
respiratory  functions. 

The  infant  should  always  be  completely  stripped  for 
examination.  We  can  then  at  once  observe  the  form  and 
play  of  the  chest,  the  state  of  the  abdomen,  the  condition 
of  the  skin,  whether  hot  or  cool,  dry  or  moist,  and  the 
conformation  of  his  limbs.  Besides,  any  eruption  upon 
the  skin  is  at  once  detected  by  this  means. 

The  large  size  of  the  belly  in  weakly  children  often 
attracts  the  attention  of  parents,  and  excites  much  anxiety. 
It  is  most  commonly  produced  by  accumulation  of  flatus, 
owing  to  the  weakness  of  the  muscular  walls.  It  may  be 
also  due  to  displacement  of  the  abdominal  contents,  such 
as  occurs  so  often  in  rickets  on  account  of  the  depression 
of  the  diaphragm  forcing  the  viscera  downwards  from 


8 


INTRODUCTION 


beneath  the  cover  of  the  ribs.  The  liver  and  spleen  may 
be  enlarged;  and  great  masses  of  sarcoma  occasionally 
spring  from  the  kidney  and  other  abdominal  organs. 
Ascites  may  be  present  from  tubercular  or  simple  perito- 
nitis, from  Bright' s  disease,  or,  rarely,  from  disease  of  the 
liver.  Tubercular  peritonitis  may  also  produce  extreme 
tympanitis.  Accumulations  of  faecal  matter  sometimes 
take  place,  and  great  enlargement  of  the  mesenteric  glands 
may  occur,  but  these  causes  are  rarely  sufficient  in  them- 
selves to  produce  any  remarkable  swelling.  If  abdo- 
minal distension  be  noticed  in  such  cases,  the  enlargement 
is  due  almost  invariably  to  gaseous  accumulation  owing  to 
fermentation  of  food. 

It  must  be  borne  in  mind  that  great  distension  of  the 
belly  in  an  infant — distension  so  great  as  to  excite  the 
anxiety  of  the  friends — is  by  no  means  necessarily  a  sign 
of  illness.  Careful  mothers  will  often  seek  medical  advice 
on  account  of  swelling  of  the  abdomen  in  their  infants. 
If  in  such  a  case  nothing  abnormal,  except  the  size,  is  to 
be  observed,  we  may  confidently  assure  the  parent  that 
there  is  nothing  to  fear. 

Even  if  the  distension  is  considerable  and  is  associated 
with  wasting,  the  evident  interference  with  nutrition  is 
not  to  be  taken  as  a  sign  that  the  abdominal  enlargement 
is  due  to  serious  disease.  Great  accumulation  of  gas  in 
the  alimentary  canal  is  the  consequence  of  fermentation 
of  food  excited  by  digestive  derangement ;  gastric  troubles 
necessarily  hinder  the  introduction  of  nutritive  material 
into  the  system,  and  in  early  life  loss  of  flesh  quickly 
follows  any  check  to  the  process  of  nutrition.  Still,  it 
is  not  uncommon  to  hear  the  symptoms  attributed  to 
mesenteric  disease,"  and  great  alarm  is  sometimes  ex- 
cited in  the  minds  of  the  j)arents  by  unfounded  apprehen- 
sions as  to  the  condition  of  the  abdominal  glands.  It 
is  well,  therefore,  to  bear  in  mind  that  distension  of  the 
abdomen  and  wasting  may  be  present  together  in  a  child 


INTRODUCTION 


9 


as  a  consequence  of  mere  disorder  of  function ;  that  casea- 
tion of  the  mesenteric  glands  is  not  common  under  the  age 
of  three  years ;  and  that,  in  any  case,  if  an  examination  of 
the  belly  detects  no  obvious  enlargement  of  these  glands, 
we  are  not  justified  in  referring  the  symptoms  to  any  form 
of  glandular  degeneration. 

In  examining  the  abdomen  the  size  of  the  liver  and 
spleen  should  always  be  investigated.  These  organs  lie 
just  below  the  surface,  and  their  lower  borders,  if  project- 
ing below  the  ribs,  can  be  readily  felt  by  placing  the  palm 
of  the  hand  flat  upon  the  belly  and  palpating  with  the  tips 
of  the  fingers.  It  is  not  enough,  however,  to  ascertain 
merely  the  inferior  limits  of  these  viscera.  Both  the  liver 
and  spleen  may  be  enlarged  although  their  lower  borders 
project  little,  if  at  all,  beyond  the  margin  of  the  ribs.  On 
the  other  hand,  their  inferior  margins  may  be  felt  some 
distance  below  the  edge  of  the  ribs,  from  displacement 
downwards  of  the  organs,  although  there  is  no  actual 
increase  in  size.  Therefore,  having  fixed  the  level  of  the 
lower  border,  we  should,  in  the  case  of  each,  proceed  to 
determine  the  upper  limit  by  percussion.  In  this  way  we 
may  find  that  the  liver  extends  upwards  to  the  third  rib, 
and  that  the  splenic  dulness  can  be  traced  as  far  as  the 
angle  of  the  scapula. 

In  the  treatment  of  chronic  wasting  in  a  young  child  our 
first  care  should  be  to  remove  any  derangement  of  the 
stomach  and  bowels.  For  this  object  a  strict  regulation 
of  his  diet  is  indispensable.  In  the  great  majority  of  such 
cases  the  cause  can  be  distinctly  traced  to  improper  feed- 
ing, and  therefore  an  alteration  in  the  diet  is  the  first  stej) 
to  a  cure.  Tonics  given  to  a  child  whose  bowels  remain 
disordered  are  of  little  service,  for,  so  long  as  the  derange- 
ment of  the  alimentary  canal  continues,  nutrition  cannot 
be  restored  on  account  of  the  impediment  thus  presented 
to  the  digestion  and  assimilation  of  food. 

Directions  on  the  subject  of  diet  cannot  be  too  precise ; 


10 


INTRODUCTION 


it  is  necessary  to  state  distinctly  not  only  the  articles  of 
food  to  be  given,  but  the  quantities  to  be  allowed  at  each 
meal,  and  the  frequency  with  which  the  meals  are  to  be 
repeated.  It  is  advisable  to  write  down  all  such  direc- 
tions, that  misunderstanding  may  be  avoided ;  in  fact,  the 
same  attention  should  be  paid  to  this  subject  as  is  paid  to 
the  ordering  of  drugs. 

After  the  diet  has  been  altered  to  suit  the  requirements 
of  the  case,  more  special  treatment  is  called  for,  and  the 
means  at  our  command  may  be  divided  into  two  classes, 
viz.  external  applications  and  internal  remedies. 

External  applications  are  of  great  service  in  all  chronic 
diseases,  for  it  is  important  to  restore  as  quickly  as  possible 
the  healthy  action  of  the  skin.  For  this  purpose,  frictions, 
counter-irritants,  and  baths,  hot  or  cold,  may  be  used. 

Frictions  can  be  employed  with  the  hand  alone,  with 
stimulating  liniments,  or  with  cod-liver  oil.  By  this  means 
the  circulation  is  rendered  more  vigorous,  and  the  action 
of  the  skin  is  promoted.  The  feebleness  of  the  circu- 
lation in  most  cases  of  chronic  disease  in  the  infant  is 
shown  by  the  coldness  of  the  extremities.  When  these 
have  been  warmed  by  suitable  applications,  the  beneficial 
influence  is  often  very  decided;  pain  in  the  belly  ceases, 
and  the  child  usually  falls  into  a  quiet  sleep.  Friction 
with  stimulating  liniments  is  merely  a  mild  form  of  counter- 
irritation  which  can  be  applied  generally,  and  has  a  more 
powerful  influence  in  stimulating  the  circulation  and  pro- 
moting a  flow  of  blood  to  the  surface,  than  friction  with 
the  hand  alone.  It  is  useful  in  all  cases  where  the  debility 
is  great. 

But  it  is  not  only  the  skin  which  is  influenced  by  such 
manipulations.  The  subject  of  manual  therapeutics  has 
lately  received  fresh  attention,  and  the  impetus  which  can 
be  given  to  healthy  tissue  change  by  a  skilful  kneading 
and  working  of  the  muscles  and  subcutaneous  structures 
has  been  taken  advantage  of  in  the  treatment  of  various 


INTRODUCTION 


11 


forms  of  chronic  disease.  Amongst  others  :  in  long  stand- 
ing cases  of  chorea  great  benefit  may  be  derived  from 
energetic  massage  of  muscle  and  manipulation  of  joints, 
so  as  to  excite  active  muscular  waste,  while  at  the  same 
time  the  increased  tissue  wants  are  satisfied  by  a  copious 
dietary:  in  rickety  children,  whose  backs  are  especially 
limp  and  powerless,  very  evident  increase  of  strength 
quickly  follows  regular  and  vigorous  shampooing ;  and  in 
obstinate  costiveness  important  results  can  be  obtained  by 
systematic  kneading  of  the  abdomen  combined  with  suit- 
able frictions. 

Rubbing  with  cod-liver  oil  is  useful  in  weakly  children, 
especially  if  the  weakness  is  associated  with  irritability  of 
stomach  and  poor  digestion.  By  this  means  a  consider- 
able amount  of  nourishment  may  be  introduced  into  the 
system.  But  oily  frictions,  or  the  mere  application  of  oil 
to  the  surface  of  the  body,  have  another  object  besides 
that  of  supplying  nourishment.  When  the  oil,  slightly 
warmed,  is  smeared  over  the  body  with  a  piece  of  fine 
sponge,  and  the  child,  wrapped  in  flannel,  is  afterwards 
placed  in  his  bed  or  cot,  one  of  the  first  effects  noticed  is 
a  profuse  general  perspiration.  This  is  accompanied  some- 
times by  a  little  erythematous  eruption,  which  resembles 
the  rash  of  measles.  At  the  same  time,  any  irritability  of 
the  nervous  system  is  quieted,  and  the  child  soon  falls  into 
a  tranquil  sleep.  A  third  effect  is  an  increase  in  the 
quantity  of  all  the  secretions :  the  urine  is  more  abundant, 
and  the  functions  of  the  liver  appear  to  be  rendered  more 
active,  for,  according  to  the  observations  of  Bauer  of 
Tubingen,  the  stools,  from  being  green  and  sour- smelling, 
become  yellow  and  natural. 

To  produce  these  effects,  it  is  not  essential  that  cod-liver 
oil  be  employed.  Other  oils  will  be  found  equally  effica- 
cious, and  are,  indeed,  generally  to  be  preferred,  on  account 
of  the  disagreeable  smell  of  the  fish  oil,  which  is  often  a 
source  of  discomfort.    Through  its  influence  in  promoting 


12 


INTRODUCTION 


the  action  of  the  Kskin,  anointing  with  oil  is  of  great  service 
in  all  the  diseases  which  are  here  treated  of,  and  in  cases 
where  the  weakness  and  emaciation  are  extreme,  striking 
results  sometimes  follow  the  application,  if  it  be  repeated 
with  sufficient  perseverance.  A  warm  bath,  or  a  thorough 
sponging  of  the  whole  body  with  very  warm  water,  im- 
mediately before  the  oil  is  applied,  is  useful  in  preparing 
the  skin  for  the  action  of  the  oil,  and  adds  greatly  to  its 
efficiency. 

In  the  application  of  counter-irritants  to  young  children 
great  care  must  be  taken  not  to  carry  the  counter- irritation 
too  far.  An  irritant  which,  in  a  healthy  child,  would 
produce  only  a  moderate  degree  of  redness,  will  often, 
where  the  strength  is  much  reduced,  set  up  very  great  in- 
flammation, or  even  produce  sloughing  of  the  tissues. 
Such  a  result  would  not  only  still  further  reduce  the 
child's  little  remaining  strength,  but  would  act  as  a  direct 
irritant  to  the  part  for  which  it  is  intended  to  be  a  deriva- 
tive. For  this  reason  counter-irritation  should,  as  a  rule, 
be  general  rather  than  local,  being  employed  m  the  form 
of  stimulating  liniments  and  hot  baths.  Sometimes, 
however,  a  local  counter-irritant  is  required.  In  these 
cases  equal  parts  of  flour  of  mustard  and  linseed  meal 
should  be  used.    Blisters  are  inadmissible  for  infants. 

For  the  hot  bath,  the  water  should  be  of  the  temperature 
of  from  95°  to  100°  Fahr.,  and  should  be  sufficient  in 
quantity  to  cover  the  child  up  to  the  neck.  After  re- 
maining in  the  water  for  three,  four,  or  five  minutes,  he 
should  be  quickly  but  thoroughly  dried,  and  be  then 
wrapped  in  flannel  and  returned  to  his  cot.  It  is  of  great 
importance  that  he  should  not  be  left  too  long  in  the  hot 
water.  The  effect  of  the  hot  bath  is  at  first  stimulating, 
but  after  stimulation  comes  reaction,  and  depression  is 
induced.  He  must  be,  therefore,  removed  before  the 
stimulating  effect  has  had  time  to  pass  off.  Children, 
especially  when  unwell,  often  show  great  repugnance  to 


INTRODUCTION 


13 


the  bath,  and  become  much  terrified  at  the  sight  of  the 
water.  In  these  cases  it  is  convenient  to  cover  the  bath 
with  a  blanket ;  the  child,  being  placed  upon  this,  can  be 
lowered  gently  down  into  the  water  without  seeing  any- 
thing to  excite  his  apprehensions. 

Sometimes  a  more  powerful  stimulant  is  required.  In 
these  cases  the  child  should  be  wrapped  in  flannel  wrung 
out  of  hot  water,  and  upon  which  some  flour  of  mustard 
has  been  sprinkled ;  the  whole  being  covered  with  a  dry 
warm  blanket.  Or  the  mustard  bath  may  be  adopted. 
For  this,  some  flour  of  mustard  is  mixed  with  cold  water, 
and  is  put  into  a  linen  bag.  The  bag  is  then  squeezed  in 
the  bath,  and  the  water  becomes  strongly  sinapised.  The 
child  is  held  in  the  warm  water  until  the  arms  of  the 
persons  supporting  him  begin  to  prick  and  tingle.  The 
quantity  of  mustard  required  for  this  bath  is  in  the  pro- 
portion of  two  ounces  to  five  gallons  of  water. 

The  immediate  effect  of  the  cold  bath  is  directly  con- 
trary to  that  of  the  hot  bath.  Its  first  effect  is  depressing, 
on  account  of  the  shock.  In  a  few  seconds,  however,  re- 
action succeeds  to  the  temporary  depression,  the  surface  of 
the  body  glows,  and  the  pulse  becomes  fuller  and  stronger. 
It  acts,  therefore,  as  a  general  stimulant  and  tonic,  pro- 
moting nutrition,  and  giving  tone  to  the  body.  If  con- 
tinued too  long,  reaction  subsides,  and  there  is  a  sense  of 
chilliness  and  languor,  with  loss  of  appetite,  which  may 
last  for  several  hours.  The  shock  is  great  in  proj^ortion 
to  the  coldness  of  the  water,  and  the  degree  of  weakness  of 
the  patient.  The  addition  of  salt  to  the  water  makes  it 
more  stimulating,  and  increases  the  vigour  of  the  reaction. 

On  account  of  these  effects  the  cold  bath  should  be  used 
with  caution,  and  is  inadmissible  until  the  child  is  far  ad- 
vanced towards  convalescence.  It  then  becomes  a  valuable 
means  of  invigorating  the  system.  The  water  should  not 
at  any  time  be  below  the  temperature  of  60°  Fahr.,  and 
should  be  used  tepid  at  the  first,  the  temperature  of  sue- 


14 


INTRODUCTION 


ceeding'  baths  being  gradually  reduced  as  the  child  gets 
stronger.    Any  chilliness  or  languor  after  the  bath  are 
signs  that  too  cold  water  has  been  used,  or  that  the  bath 
has  been  continued  too  long.    To  be  beneficial  the  whole 
process  should  be  rapid.    The  child  should  be  quickly 
sponged,  and  should  then  be  dried  briskly  with  a  thick 
soft  towel.    The  whole  body  should  be  afterwards  well 
and  firmly  rubbed  with  the  open  hand  to  assist  the  re- 
action.   In  the  case  of  delicate  children,  when  a  cold  bath 
is  used,  it  is  advisable  to  prepare  the  skin  for  the  action  of 
the  cold  water  by  a  vigorous  shampooing  of  the  spine  and 
the  body  generally.    By  this  means  the  skin  is  stimulated 
to  resist  the  shock,  and  reaction  is  promoted.    The  shock 
is  also  diminished  by  allowing  the  child  to  sit  with  his 
feet  and  a  few  inches  of  his  body  in  hot  water  (100°) 
while  a  pitcher  of  water  at  a  temperature  of  65°  Fahr.  is 
rapidly  emptied  over  his  shoulders.    By  the  use  of  such 
precautions  weakly  children  may  make  use  of  the  cold  bath 
without  discomfort,  and  with  the  greatest  benefit  to  their 
health. 

Of  i7iternal  remedies  little  need  be  said  in  this  place,  as 
full  directions  will  be  given  afterwards  in  considering  the 
treatment  of  the  various  diseases.  The  important  point 
to  remember  is  the  uselessness  of  tonics  so  long  as  any 
derangement  of  the  digestive  organs  remains  uncorrected. 
In  order  that  tonics  may  be  beneficial,  the  stomach  and 
bowels  must  be  in  a  healthy  state.  It  is  only  when 
digestion  is  restored  that  these  remedies  are  admissible. 
They  will  then  prove  of  extreme  service,  increasing  the 
vigour  of  the  stomach,  and  improving  the  tone  of  the 
whole  body. 

To  the  general  list  of  tonics  cod-liver  oil  is  an  im- 
portant addition.  It  is,  indeed,  more  a  food  than  a 
medicine ;  but  for  this  very  reason  it  should  not  be  given 
in  too  large  quantities.  If  too  large  a  dose  of  the  oil  is 
given,  only  a  portion  becomes  digested.     The  remainder 


INTRODUCTION 


15 


passes  down  through  the  bowels,  and  is  seen  unchanged 
in  the  stools,  where  it  is  at  once  recognised  by  its  appear- 
ance and  smell.  In  administering  the  oil  our  object  should 
be  to  give  as  much  as  can  be  readily  digested,  but  no 
more.  For  a  child  under  two  years  of  age  ten  drops  will 
be  a  sufficient  dose  at  the  first.  The  quantity,  after  the 
first  few  days,  can  be  gradually  increased,  but  a  careful 
watch  must  be  kejyt  upon  the  stools,  and  the  aj^pear- 
aiice  of  any  oil  unchanged  in  the  evacuations  is  a  sign 
that  the  quantity  must  be  reduced.  For  a  child  of 
this  age  we  can  seldom  go  beyond  twenty  drops  for 
the  dose,  three  times  in  the  day.  It  must  always  be 
remembered  that  the  oil  is  an  addition  to,  not  a  sub- 
stitute for,  other  food,  and  is  therefore  only  useful  so 
long  as  it  is  well  borne  by  the  stomach.  If  it  be  found 
to  impair  the  appetite,  or  to  interfere  in  the  slightest 
degree  with  digestion,  its  use  should  be  immediately  dis- 
continued. 

With  regard  to  stimulants  ;  they  are  always  required 
when  the  fontanelle  becomes  much  depressed.  The  best 
form  for  infants  is  pale  brandy,  of  which  a  few  drops 
(five  to  ten)  may  be  given  in  cold  water  or  a  little  milk, 
as  often  as  circumstances  seem  to  demand  the  repetition. 
For  older  children  the  brandy-aiid-egg  mixture  of  the 
pharmacopoeia  makes  the  best  stimulant. 


CHAPTER  I 


INFANTILE  ATROPHY 

INFANTILE  atrophy,  or  simple  wasting  from  insuffi- 
cient nourishment,  is  one  of  the  commonest  causes  of 
death  in  infants  under  twelve  months  old.  Many  thou- 
sand children  die  yearly  in  London  alone  for  the  simple 
reason  that  they  are  fed  with  food  which  they  cannot 
digest.  And  it  is  not  only  amongst  the  children  of  the 
poor  that  this  form  of  marasmus  is  to  be  found.  Infan- 
tile atrophy  is  common  in  all  classes  of  life,  for  it  is  to 
faulty  feeding,  as  a  rule,  rarely  to  actual  want  of  food, 
that  the  wasting  is  to  be  ascribed. 

It  may  happen,  however,  that  there  is  a  real  deficiency 
in  the  food  supply.  If  an  infant  depend  solely  upon  the 
breast  of  a  mother  whose  milk,  although  abundant,  is 
poor  and  watery  ;  or  if  suckling  be  protracted  to  a  period 
when  more  substantial  food  is  required,  the  nutrition  of 
the  child  in  either  case  must  be  unsatisfactory. 

When  the  mother  is  weak,  anaemic,  and  evidently  ill- 
nourished,  her  milk  no  doubt  always  suffers  from  the 
impoverished  state  of  her  blood ;  but  the  converse  of  this 
is  not  always  the  case,  for  the  milk  of  a  woman  may  still  be 
of  very  inferior  quality,  although  in  her  health  and  general 
appearance  she  present  no  sign  of  weakness.  MM. 
Yernois  and  Becquerel  showed  long  ago  that  it  is  not 
women  of  the  greatest  muscular  development  who  yield 
the  richest  milk  ;  but  that,  on  the  contrary,  a  robust  figure 
may  be  inferior  in  milk-j^roducing  power  to  one  slighter 
and  less  apparently  vigorous. 


VARIATIONS  IN  WOMAn's  MILK 


17 


Analysis  of  breast-milk  taken  from  different  nursing 
mothers  shows  remarkable  variations  in  the  proportion  of 
the  several  constituents.  In  the  course  of  an  inquiry,  in 
which  ninety-four  samples  were  examined,  Dr.  A.  H.  Carter 
and  Mr.  H.  D.  Richmond  found  that  the  fat  varied  from 
8*802  per  cent,  to  0'47  per  cent.  ;  the  proteids  from  4*05 
to  1-02  ;  and  the  sugar  from  8'89  to  4-38  per  cent.  On 
account  of  this  wide  diversity  in  the  composition  of  human 
milk  we  cannot  wonder  that  infants  do  not  always  thrive 
at  the  breast  or  that  the  choice  of  a  wet  nurse  is  often  dis- 
appointing. The  milk  may  be  good  enough  in  itself  and 
yet  fail  to  nourish  the  infant  who  takes  it ;  indeed,  a  breast- 
milk  which  suits  one  child  may  upset  another,  for  if  from 
excess  of  proteids  or  fat  the  milk  prove  too  heavy  for  a 
child's  digestion,  the  result  as  regards  that  particular 
nurseling  cannot  be  satisfactory.  Still,  all  we  can  do  in 
choosing  a  wet-nurse  is  to  ascertain  the  state  of  her  health 
and  the  quality  of  her  milk,  leaving  the  suitability  of  her 
milk  to  the  individual  infant  to  be  determined  later  by 
actual  experience. 

For  practical  purposes  we  may  make  a  guess  at  the 
goodness  and  quantity  of  the  milk  by  inspection  of  the 
breasts  of  the  mother  or  nurse.  They  should  be  pear- 
shaped,  hardish,  and  mottled  with  blue  veins.  On  pres- 
sure of  the  gland  the  milk  should  squirt  out.  The  milk 
itself  should  be  opaque  and  of  a  dull  white  colour.  Under 
the  microscope  it  should  present  fat  globules  of  medium 
size,  not  too  small.  As  a  rule,  the  number  of  fat  globules 
is  a  rough  indication  of  the  quantity  of  casein  and  sugar, 
although  this  is  not  always  a  trustworthy  guide.  The 
best  test,  however,  of  the  goodness  of  the  milk  is  derived 
from  observation  of  the  child.  He  should  be  watched 
while  at  the  breast,  and  if  he  sucks  vigorously,  finishes 
the  meal  with  the  milk  running  over  his  lips,  and  requires 
to  suck  but  a  few  times  in  the  day,  we  may  infer  that  the 
milk  is  sufficiently  abundant.    If,  on  the  other  hand,  he 

2 


18 


INFANTILE  ATROPHY 


constantly  requires  the  breast,  sucks  laboriously  and  with 
effort,  occasionally  desisting  and  crying  peevishly,  the 
milk  is  probably  scanty.  As  an  additional  test,  the  infant 
may  be  weighed  immediately  before  and  after  taking  the 
breast ;  the  increase  in  weight  should  be  from  three  to  six 
ounces,  according  to  his  age. 

Even  if  the  breast  milk  be  poor  or  scanty,  it  is  rare  for 
infantile  atrophy  to  arise  from  failure  in  the  quantity  of 
food  supplied,  as  there  is  seldom  any  lack  of  readiness  to 
make  good  the  deficiencies  of  the  breast.  As  a  rule,  it  is 
not  the  quantity  but  the  quality  of  the  food  which  is  at 
fault,  for  the  inflow  of  nutritive  material  may  still  fall 
greatly  short  of  the  infant's  wants,  although  the  supply  of 
food,  as  food,  is  liberal  enough.  We  see  this  in  cases 
where  a  child  is  brought  up  by  hand,  either  wholly  or 
partially,  and  fed  with  a  food  which  is  ill-suited  to  his 
limited  digestive  power.  Here  the  diet  substituted  for 
the  mother's  milk,  although  nutritious  enough  in  itself, 
supplies  little  nutriment  to  the  infant.  A  child  is  not 
nourished  in  proportion  to  the  bulk  of  the  food  he  receives 
into  his  stomach.  He  is  only  nourished  by  the  food  he 
can  digest.  Weakness  in  a  child  otherwise  healthy,  while 
it  shows  a  deficient  degree  of  nutrition,  and  therefore  calls 
for  an  increased  supply  of  nourishment,  calls  at  the  same 
time  for  increased  care  in  the  selection  of  the  Mnd  of  food. 
There  is  a  difference  between  food  and  nourishment.  A 
child  may  take  large  quantities  of  food  into  his  stomach, 
but  from  weakness  of  his  digestive  organs,  or  from  the 
indigestible  nature  of  the  food  swallowed,  may  derive  no 
nourishment  from  it  whatever.  On  the  contrary,  it  may 
cause  great  irritation  and  pain  in  the  alimentary  canal, 
and,  setting  up  a  febrile  state,  still  further  reduce  the 
child  whom  it  was  intended  to  support.  The  tendency  of 
mothers  is  to  overfeed  their  children — to  mistake  every 
cry  for  the  cry  of  hunger.  Consequently,  as  the  peevish- 
ness and  irritability  of  the  child  increase  in  proportion  to 


CAUSATION 


19 


the  pain  excited  in  the  bowels,  the  food  is  made  more  and 
more  "  nourishing,"  until  at  last  a  violent  attack  of  vomit- 
ing or  of  diarrhoea  takes  place,  or  a  convulsive  fit  warns 
the  parent  that  it  is  time  to  desist.  Cases  of  steady 
emaciation  will  be  constantly  found  due  to  this  cause, 
especially  in  children  who  are  brought  up  by  hand. 
Amongst  the  poorer  classes  they  are  commonly  fed  upon 
farinaceous  food  as  soon  as  they  are  born.  This,  of  course, 
they  are  totally  unable  to  digest.  As  a  consequence,  they 
dwindle  and  rapidly  die,  or  if  of  particularly  robust  con- 
stitution, linger  on,  weak,  ailing,  and  rickety,  until  an 
attack  of  bowel  complaint,  or  other  intercurrent  disease, 
carries  them  off.  The  very  fact  that  the  secretion  of  saliva 
in  the  young  child  does  not  become  established  until  the 
third  month  after  birth,  seems  to  indicate  that  before  that 
age  farinaceous  articles  of  diet  are  unsuited  to  the  infant, 
as  saliva  is  one  of  the  most  important  agents  in  the  diges- 
tion of  starchy  foods.  Besides,  for  perfect  nutrition  four 
classes  of  food  are  required — viz.  albuminates,  fatty  sub- 
stances, carbo-hydrates,  and  salts.  These  are  found  in 
the  most  digestible  form  and  the  most  perfect  proportions 
for  the  young  child  in  the  casein,  fat,  sugar,  and  salts  of  - 
the  human  milk.  The  casein  supplies  the  waste  of  the 
nitrogenous  tissues,  as  the  muscles,  and  probably  the 
brain  and  nerves,  and  by  its  oxidation,  when  it  has  formed 
part  of  these  tissues,  contributes  also  to  animal  heat.  The 
fat  is  essential  to  the  formation  of  muscular  and  nervous 
tissues,  and  also  aids  by  its  oxidation  in  the  production  of 
heat.  The  sugar  is  probably  entirely  heat-giving.  The 
salts  form  the  necessary  constituents  of  all  tissues. 

In  nutrition,  it  is  important  that  tissue  change  should 
be  rapid,  and  in  young  children,  in  whom  development  as 
well  as  growth  is  so  brisk,  this  is  of  special  importance. 
It  is  effected  by  the  oxidation  of  old  material,  which  is 
then  removed,  to  be  replaced  by  new  matter.  For  rapid 
change,  therefore,  it  is  indispensable  that  no  needless  im- 


20 


INFANTILE  ATROPHY 


pediment  should  exist  to  the  free  oxidation  of  the  tissues. 
Now,  starches,  and  sugars  into  which  the  starches  are 
converted  by  digestion,  have  a  greater  affinity  for  oxygen 
than  albuminates  ;  they,  therefore,  tend  to  appropriate 
the  oxygen  which  is  required  for  the  removal  of  waste 
matters,  and  so  to  prevent  the  proper  changes  from  taking 
place.  For  this  reason  alone,  and  without  any  reference 
to  their  indigestible  properties,  they  form  a  very  unsuit- 
able diet  for  a  young  child. 

Even  those  children  who  are  fed  entirely  on  cow's  milk 
are  not  free  from  danger.  By  referring  to  the  table  ^  we 
see,  in  comparing  the  milk  of  the  cow  with  human  milk, 
that  the  former  contains  a  considerably  larger  quantity  of 


Water. 

Sugar. 

Casein. 

Fat. 

Ash. 

Woman's  milk  . 

87-163 

7*407 

1-046 

4-283 

•101 

Cow's  milk  . 

88-549 

4-898 

2-792 

3-310 

•451 

casein.  On  the  other  hand,  the  pro]Dortion  of  sugar  and 
cream  is  less  than  that  found  in  human  milk.  In  adapt- 
ing it,  therefore,  as  a  substitute  for  the  natural  food  of  the 
child,  it  will  be  necessary  to  remedy  these  differences  by 
dilution  with  water,  and  by  the  addition  of  a  small  quan- 
tity of  sugar  of  milk.  But  this  is  not  enough.  There  is 
another  distinction  between  the  two  fluids  which  it  is 
extremely  important  to  take  into  consideration.  On  the 
addition  of  rennet,  the  casein  of  human  milk  coagulates 
into  light,  loose  clots,  formed  by  the  aggregation  of  little 
flocculi,  while  that  of  cow's  milk  congeals  into  heavy,  com- 
pact lumps.  The  same  thing  takes  place  in  the  stomach 
of  the  child,  as  is  shown  by  producing  vomiting  in  an 
infant  directly  after  a  meal  by  friction  over  the  belly :  the 
*  Dr.  A.  V.  Meigs,  *  Archives  of  Pediatrics,'  April,  1884, 


CAUSATION 


21 


light,  loose  clots  formed  from  human  milk  are  then  readily 
distinguishable  from  the  dense  masses  of  casein  produced 
by  coagulation  of  the  milk  of  the  cow.  The  difference  in 
the  digestibility  of  these  two  products  is  very  evident. 
While  the  one  is  readily  assimilated  without  any  undue 
demand  upon  the  digestive  powers,  the  other  tasks  these 
powers  to  the  utmost,  and,  unless  a  very  moderate  quan- 
tity has  been  taken,  will  undergo  fermentation,  and  give 
rise  to  much  flatulence,  colic,  and  perhaps  diarrhoea  in  its 
progress  along  the  alimentary  canal. 

Children  are,  no  doubt,  frequently  found  to  thrive  upon 
this  diet,  their  digestive  power  being  equal  to  the  demands 
made  upon  it.  Others,  however,  and  by  far  the  larger 
proportion,  are  not  equal  to  this  daily  call  upon  their 
powers.  They  cannot  assimilate  this  mass  of  curd.  Con- 
sequently, unless  rejected  by  vomiting,  the  meal  passes 
through  them  undigested ;  their  wants  are  not  supplied ; 
and  they  starve  for  lack  of  nourishment,  although  swal- 
lowing every  day  a  quantity  of  milk  which  would  be  ample 
support  to  a  stronger  and  healthier  infant.  Such  children 
are  exceedingly  restless  and  irritable.  They  cry  day  and 
night ;  at  one  time  from  abdominal  pains  excited  by  the 
presence  in  the  bowels  of  this  undigested  mass  ;  at  others 
from  the  hunger  which  the  passage  of  this  meal  has  failed 
to  appease.  The  nurses  say,  very  truly,  that  the  child 
is  ravenous,"  and  that  "  the  milk  does  not  satisfy  him  ;  " 
but  the  baked  flour,  the  infant's  biscuits,  and  the  tops 
and  bottoms "  by  which  they  propose  to  themselves  to 
attain  that  end  are  by  no  means  calculated  to  do  so.  In- 
stead of  mitigating  his  distress,  they  aggravate  it;  and 
every  additional  meal,  although  it  may  quiet  him  for  the 
time,  forms  a  subject  for  future  complaints.  It  is,  how- 
ever, often  very  difficult  to  persuade  mothers  and  nurses  of 
the  importance  of  what  has  been  stated.  They  see  that 
the  child  is  wasting  under  the  diet  they  have  first  adopted, 
and  therefore  insist  that  something  more  solid  must  be 


22 


INFANTILE  ATROPHY 


required.  It  is  necessary  to  impress  upon  them  very 
strongly  tliat  a  child  may  actually  starve  on  the  fullest 
diet ;  and  that  the  presence  of  large  quantities  of  farin- 
aceous or  caseous  matters  in  the  alimentary  canal  is  not 
necessarily  followed  by  any  additional  supply  of  nourish- 
ment to  the  tissues.  In  all  cases  where  the  food  of  a-n 
infant  is  said  by  nurses  to  be  insufficient  the  stools  should 
be  examined,  and  if,  as  is  so  frequently  the  case,  they  are 
found  to  consist  of  pale,  round,  hard  lumps,  exhibiting  in 
their  interior  the  cheesy  appearance  so  characteristic  of  a 
mass  of  curd,  we  may  safely  conclude  that  it  is  not  too 
little  that  is  being  given,  but  too  much ;  and  by  taking  the 
necessary  care  we  may  succeed  in  providing  the  child  with 
a  diet  he  is  capable  of  digesting. 

Besides  the  weakness  produced  by  the  withholding  of 
nourishment,  there  is  an  additional  cause  of  debility  in 
the  constant  attacks  of  vomiting  and  diarrhoea,  to  which 
this  indigestible  diet  invariably  leads.  Each  of  these 
attacks  reduces  him  more  and  more,  and  by  weakening  his 
digestive  powers  renders  him  less  than  ever  able  to  obtain 
any  nourishment  from  the  food  with  which  he  is  supplied. 

Symptoms. — The  symptoms  of  simple  wasting  from  in- 
sufficient nourishment  may  be  divided  into  two  classes, 
according  to  the  nature  and  quality  of  the  food  taken : — 

Food  suitable  but  insufficient. 

Food  unsuitable. 

In  the  first  of  these  classes  there  are  no  very  striking 
symptoms.  The  infant  gradually  loses  his  plumpness ; 
his  fat  slowly  disappears ;  and  the  muscles  get  very  flaccid 
and  soft.  He  does  not  seem  to  grow.  His  face  becomes 
pale,  and  his  lips  pale  and  thin.  He  is  peevish  as  a  con- 
sequence of  his  hunger ;  takes  the  breast  ravenously  at  the 
first,  and  then,  if  the  secretion  of  milk  is  scanty,  desists  at 
intervals  to  cry  passionately  as  if  in  vexation  at  his 
inability  to  obtain  the  means  of  satisfying  his  wants.  His 
skin  is  moist,  and  he  perspires  readily  and  copiously.  The 


SYMPTOMS 


23 


fontanelle  is  level  or  slightly  depressed,  At  night  he  is 
exceedingly  irritable  and  sleepless.  In  the  daytime  he 
will  often  lie  quietly  enough,  holding  both  thumbs  in  his 
mouth,  and  sucking  at  them  until  the  skin  at  the  sides  of 
the  nail  becomes  raw  and  abraded.  If  the  milk  is  poor 
but  abundant,  the  child  is  usually  very  quiet  and  drowsy, 
passing  almost  all  his  time  asleep,  He  may  even  sleep 
while  at  the  breast — a  sure  sign  that  the  milk  is  thin  and 
serous.  The  bowels  are  usually  confined,  and  the  motions 
rather  solid,  although  otherwise  natural.  No  symptoms 
are  found  to  indicate  disease  of  any  particular  part  of  the 
body. 

In  this  class  of  cases  nutrition  is  defective  on  account 
of  the  inferior  quality  and  insufficient  quantity  of  the 
mother's  milk,  and  nothing  is  added  to  compensate  for 
tliese  defects.  The  remedy  is,  of  course,  to  supply  the 
deficiency.  When  the  required  nourishment  is  given,  the 
wasting  stops  at  once,  the  peevishness  ceases,  and  the 
child,  rapidly  regaining  flesh,  becomes  strong  and  healthy. 

In  the  second  class  of  cases,  where  the  food  is  bad  in 
quality,  we  find  the  symptoms  produced  by  the  irritation 
of  the  digestive  organs  to  which  the  presence  of  indigest- 
ible food  necessarily  gives  rise.  The  child  is  dull  and 
languid,  his  flesh  becomes  flabby,  and  he  begins  to  waste. 
The  skin  is  moist  at  the  first,  although  afterwards  it  is  apt 
to  become  dry,  except  about  the  head ;  and  the  fontanelle 
is,  or  soon  becomes,  depressed.  The  face  and  body  gene- 
rally are  pale,  and  the  complexion  sometimes  turns  yellow- 
ish, assuming  a  half -jaundiced  tint,  which  remains  several 
hours,  or  even  days,  and  then  disappears.  The  tongue  is 
clean,  pink,  and  moist,  and  remains  so  long  as  there 
are  no  symptoms  of  acute  digestive  disturbance.  The 
bowels  are  irregular  and  capricious  ;  constipation  alter- 
nating with  occasional  attacks  of  diarrhoea.  The  common 
condition  is  constipation  ;  a  stool  occurring  every  second 
day  consisting  of  hard,  whitish  lumps,  covered  with  a 


24 


INFANTILE  ATROPHY 


stringy  iiiucus,  and  formed  almost  entirely  of  undigested 
food.  Its  evacuation  is  often  attended  with  much  strain 
ing,  and  may  be  preceded  by  some  pain  in  the  belly.  The 
cause  of  this  sluggishness  of  the  bowels  is  the  presence  of 
mucus  secreted  in  unusual  quantities  on  account  of  the 
irritation  to  which  the  membrane  lining  the  alimentary 
canal  is  exposed.  This  mucus,  being  coagulated  by  the 
acid  resulting  from  the  decomposition  of  the  starchy  food, 
covers  the  contents  of  the  bowels,  and  also  forms  a  tena- 
cious lining  round  the  inner  surface  of  the  intestine. 
Consequently  the  bowels,  in  their  peristaltic  action,  glide 
over  the  slippery  surface  of  the  masses  of  food,  and  lose 
their  power  of  propelling  these  forwards  towards  the  out- 
let. Sometimes,  however,  instead  of  being  confined,  the 
bowels  are  open  three  or  four  times  a  day,  the  stools  being 
green,  half-liquid,  slimy,  and  extremely  offensive.  In 
either  case  the  food  which  the  child  has  taken  passes 
through  him  without  being  digested. 

Flatulence  is  a  source  of  great  annoyance  to  the  infant. 
It  may  cause  paroxysms  of  violent  pain,  in  which  the  face 
becomes  white,  the  upper  lip  livid  and  everted,  and  the 
belly  tense.  The  child  utters  piercing  cries,  at  the  same 
time  drawing  up  the  lower  limbs  suddenly  and  violently 
upon  the  abdomen.  Even  during  sleep  frequent  startings 
and  moanings,  elevation  of  the  corners  of  the  mouth,  and, 
if  the  pain  be  severe,  a  contraction  of  the  brows,  show 
that  the  child  is  suffering  from  abdominal  pains.  The 
smile  which  is  sometimes  seen  upon  the  child's  face 
during  sleep  is  a  result  of  the  same  cause,  although,  of 
course,  to  a  much  less  degree.  The  wind  is  often  evacu- 
ated in  large  quantities,  or  comes  up  as  sour- smelling 
eructations,  affording  great  relief.  During  the  attacks  of 
colic  the  action  of  the  kidneys  seems  to  be  suspended,  and 
the  termination  of  the  spasm  is  generally  accompanied  by 
a  copious  discharge  of  urine.  The  temper  is  exceedingly 
irritable.     The  i^ain  and  uneasiness  from  which  these 


SYMPTOMS 


25 


children  suffer,  and  which  is  constantly  being  renewed  by 
every  additional  meal,  makes  them  noisy  in  their  lamen- 
tations to  a  degree  which  is  almost  unbearable.  As  the 
mothers  say,  "they  wear  one's  life  out."  At  night  this 
is  especially  the  case.  At  that  time  they  are  apt  to  be 
feverish,  and  are  often  seized  with  fits  of  screaming 
which  nothing  will  appease  and  which  sometimes  con- 
tinue until  actual  exhaustion  compels  them  to  desist. 
Even  then,  however,  the  cries  are  renewed  at  intervals,  as 
a  fresh  attack  of  abdominal  pain  rouses  them  from  uneasy 
sleep.  At  these  times  the  feet  are  usually  cold,  although 
the  belly,  hands,  and  cheeks  may  be  dry  and  hot. 

But  in  spite  of  all  this,  or  rather  as  a  consequence  of  it, 
the  appetite  is  usually  enormous.  The  uneasiness  pro- 
duced by  acidity  and  flatulence  will  often  excite  in  children 
a  great  desire  for  food  ;  and  unless  the  uneasiness  amount 
to  actual  pain,  they  will  swallow  ravenously  whatever  is 
offered  to  them.  The  amount  of  farinaceous  matter  an 
infant  will  consume  in  this  way  is  sometimes  very  large  ; 
and  the  fact  that,  in  spite  of  such  voracity,  the  child  should 
still  continue  to  waste,  excites  much  wonder  amongst  his 
attendants. 

Attacks  of  nettlerash  and  strophulus,  either  separately 
or  combined,  are  very  common.  With  the  appearance  of 
nettlerash  every  one  is  familiar.  Strophulus  may  be  either 
of  the  red  or  the  white  variety. 

Red  strophulus  (red-gum)  begins  as  a  red  blotch,  the 
centre  of  which  is  slightly  elevated.  The  redness  soon  fades, 
and  the  central  elevation  enlarges  and  forms  a  flattened 
papule,  often  of  considerable  size.  These  are  seated  on  the 
face,  neck,  arms,  and  sometimes  cover  the  whole  body. 

White  strophulus  appears  in  the  form  of  pearly  white 
opaque  papules,  smaller  than  the  preceding,  and  about 
the  size  of  a  small  pin's  head.  They  are  seen  usually  on 
the  face  and  arms. 

The  presence  of  either  of  these  eruptions  (nettlerash  or 


26 


INFANTILE  ATROPHY 


strophulus)  oil  the  body  of  a  young  child  is  a  certain  sign 
of  digestive  derangement. 

Thrush  (parasitic  stomatitis)  is  another  consequence  of 
the  unsuitable  diet  to  which  the  child  is  exposed,  and  is 
especially  common  in  warm  weather.  The  mucous  mem- 
brane of  the  mouth  becomes  red ;  then  little  concretions, 
transparent  at  first,  afterwards  pearly  white,  appear  on 
the  reddened  surface,  unite,  and  form  patches  varying  in 
size,  and  looking  like  little  bits  of  curd  adhering  to  the 
tongue,  and  to  the  inside  of  the  cheeks  and  lips.  In  very 
bad  cases  they  line  the  whole  interior  of  the  mouth,  and 
may  extend  into  the  fauces,  down  the  gullet,  and  even, 
according  to  Parrot,  into  the  stomach  and -intestines.  At 
the  same  time  there  is  a  little  febrile  disturbance,  with 
some  thirst ;  usually  vomiting  ;  and  often  a  thin  watery 
diarrhoea,  from  the  irritation  of  deranged  intestinal  secre- 
tions. If,  as  frequently  happens,  the  nates  become  red 
and  excoriated  by  the  discharges  from  the  bowels,  the 
thrush  is  said  by  nurses  to  have  "  gone  through "  the 
child.  There  is  some  tenderness  of  the  mouth,  and  if  the 
child  be  put  to  the  breast  in  the  course  of  tbis  complaint, 
he  often  refuses  to  suck  on  account  of  the  pain  excited  by 
the  movement  of  the  tongue  and  cheeks. 

The  concretions  are  due  to  a  cryptogamic  vegetation, 
oidium  albicans,  which  appears  to  be  identical  with  the 
sacchoromyces  mycoderma,  or  mould  of  wine.  Its 
sporules  multiply  with  great  rapidity,  and  form  tubular 
fibrils.  These  with  an  increased  formation  of  epithelial 
scales,  constitute  the  white  patches  seen  on  the  mucous 
membrane.  The  plant  finds  a  nidus  in  the  altered  secre- 
tions of  the  mouth. 

This  is  either  a  mild  or  a  severe  complication,  according 
to  the  general  condition  of  the  child  in  whom  it  is  found. 
If  it  occur  in  a  child  who  has  been  reduced  to  a  state  of 
great  weakness  by  a  long  course  of  improper  food,  it  is  of 
very  unfavourable  augury,  for  in  such  a  case  our  hopes  of 


SYMPTOMS 


27 


-improving  his  health  dexjend  upon  the  rapidity  and  com- 
pleteness with  which  new  material  for  nutrition  can  be 
introduced  into  the  system.  Anything,  therefore,  which 
tends  to  prevent  the  introduction  of  nourishment  tends  to 
deprive  the  child  of  this  his  only  means  of  recovery  ;  and 
the  presence  of  thrush  betrays  a  condition  of  the  digestive 
passages  extremely  unfavourable  to  the  ready  assimilation 
of  food.  Moreover,  the  diarrhoea  which  is  so  apt  to 
accompany  the  disorder,  especially  in  weakly  children,  is 
another  reason  for  regarding  the  occurrence  of  this  com- 
plication, in  such  cases,  with  considerable  anxiety. 

In  stronger  children,  want  of  cleanliness,  or  temporary 
derangement  set  up  by  improper  food,  may  give  rise  to 
thrush ;  but  here,  if  the  strength  is  satisfactory,  recovery 
is  usually  rapid :  the  concretions  become  greyer,  then 
yellow  ;  fall  off,  and  are  not  renewed. 

Another  symptom  of  the  irritation  excited  by  unsuit- 
able food  is  that  known  in  nurseries  under  the  name  of 

inward  fits."  The  phenomena  which  constitute  the  con- 
dition denoted  by  this  rather  vague  expression,  are  a  blue- 
ness  or  lividity  of  the  upper  lip,  which  is  rather  everted, 
and  may  twitch ;  a  slight  squint,  or  a  peculiar  rotation  of 
the  eye ;  with  contraction  of  the  fingers,  and  twisting 
inwards  of  the  thumbs.  These  symptoms  should  never  be 
disregarded,  as  they  are  often  the  precursors  of  an  attack 
of  convulsions. 

If  a  great  accumulation  of  food  has  taken  place  in  the 
alimentary  canal,  or  if  the  child  has  swallowed  some  sub- 
stance which  is  more  than  usually  indigestible,  or  has  been 
exposed  to  cold,  the  symptoms  may  become  more  alarming. 
The  skin  gets  very  hot,  the  face  flushed,  and  there  is 
violent  vomiting  of  sour- smelling  food,  with  mucus,  pre- 
ceded by  great  retching.  The  efforts  to  vomit  may  con- 
tinue after  the  stomach  has  been  emptied,  and  then  green 
or  yellow  bile  is  thrown  up.  At  the  same  time  the  bowels 
become  very  loose,  and  large,  dark  green,  or  putty-like, 


28 


INFANTILE  ATROPHY 


offensive  motions  are  passed,  with  great  straining.  The 
motions  often  contain  little  lumps,  and  each  action  of  the 
bowels  is  preceded  by  much  griping,  during  which  the 
child  screams,  draws  up  his  legs,  and  throws  himself 
uneasily  from  side  to  side.  The  tongue  is  rather  dry,  and 
is  thickly  coated,  white  or  yellow,  with  large,  round,  red 
or  pink  papillae  scattered  over  its  surface,  peering  through 
the  fur.  The  belly  is  full,  rather  hard,  and  irregular  to 
the  touch.  The  child  refuses  all  food,  but  is  very  thirsty ; 
he  usually,  however,  vomits  the  fluid  he  has  taken  very 
shortly  after  swallowing  it.  Sometimes  a  convulsive  fit 
ushers  in  this  attack,  and  may  be  repeated  several  times. 
Occasionally  these  fits  recur  in  such  numbers,  and  with 
such  violence,  as  to  cause  death  by  the  exhaustion  they 
induce.  The  vomiting  usually  ceases  after  the  first  day, 
or  is  repeated  at  longer  intervals,  but  the  diarrhoea  con- 
tinues for  two  or  three  days,  unless  treatment  be  quickly 
had  recourse  to,  and  the  motions  change  their  character, 
becoming  watery,  and  usually  of  a  brown  colour,  still 
remaining  extremely  offensive.  If  the  straining  be  great, 
there  may  be  slight  prolapse  of  the  bowel,  with  a  little 
blood  in  the  form  of  red  streaks  in  the  motions. 

In  children  over  twelve  months  old,  such  attacks  are 
often  accompanied  by  aphthae  of  the  mouth.  These  are 
found  on  the  tip  of  the  tongue,  round  the  anterior  part  of 
its  margin,  and  on  the  inside  of  the  lower  lip.  They 
consist  of  small  circular  superficial  ulcers  seated  at  the 
follicles  of  the  mucous  membrane.  At  the  same  time  the 
lower  gums  are  usually  red,  swollen,  and  shining ;  they 
easily  bleed,  and  may  be  ulcerated  along  the  roots  of  the 
incisor  teeth.  There  is  also  increased  secretion  from  the 
mucous  membrane  of  the  mouth,  with  some  salivation. 
The  number  of  the  aphthae  varies  from  two  or  three  to 
fifteen  or  even  twenty.  They  are  very  rarely  solitary, 
usually  about  five  or  six. 

When  the  attack  subsides,  the  infant,  unless  a  better 


SYMPTOMS 


29 


system  of  management  be  adopted,  goes  on  as  before,  the 
wasting  continues,  and  he  becomes  gradually  weaker  and 
more  languid.  The  attacks  of  acute  indigestion  recur  at 
short  intervals,  each,  as  it  passes  off,  leaving  him  more 
prostrate,  and  less  able  to  withstand  the  injurious  influ- 
ences which  are  gradually  wearing  away  his  life.  His 
face  becomes  wrinkled  and  old-looking ;  his  eyes  dull  and 
heavy;  his  expression  languid,  or  peevish;  and,  as  his 
debility  increases,  the  griping  pains  to  which  he  is  still 
subject  excite  no  longer  a  fretful  cry,  but  only  a  plaintive 
moan ;  or  merely  a  contraction  of  the  features  without  any 
sound.  His  emaciation  becomes  extreme ;  his  belly  large  ; 
his  skin  harsh  and  dry ;  his  fontanelle  deejDly  depressed ; 
and,  finally,  some  secondary  disease  arises,  and  puts  an 
end  to  his  existence.  Any  acute  disease  attacking  a  child 
in  such  a  condition  is  almost  certainly  fatal,  for  all 
resisting  power  has  been  starved  out  of  him,  and  he  falls 
a  ready  victim  to  a  disorder  which,  in  a  healthy  child, 
would  be  easily  manageable,  and  quickly  cured.  A  nephri- 
tis is  readily  set  up  in  such  impressionable  subjects,  and  is  a 
not  uncommon  complication  towards  the  end.  The  renal 
condition  may  be  due,  as  Czerny  and  Moser  believe,  to 
micro-organisms  carried  into  the  circulation  from  the 
alimentary  tract.  M.  Simmonds  avers  that  the  middle  ear 
is  the  source  of  the  mischief.  He  found  evidence  of  otitis 
media  in  twenty-eight  out  of  twenty-nine  necropsies  ;  and 
states  that  the  tympanic  cavity  contained  Friedlander's 
bacillus,  Fraenkel's  diplococcus,  streptococcus  pyogenes 
and  other  dangerous  microbes.  Consequently  he  asserts 
that  middle  ear  disease  with  resulting  degeneration  of  the 
kidneys  must  be  one  of  the  commonest  causes  of  death  in 
wasting  infants. 

If  the  child  has  been  brought  up  entirely  by  hand,  and 
has  been  fed  improperly  from  his  very  birth,  he  seldom  lives 
longer  than  two  or  three  months.  If  he  has  been  suckled 
for  some  months  before  he  begins  to  take  the  improper  food. 


30 


INFANTILE  ATROPHY 


he  has  greater  j^ower  of  resistance;  and  although  under 
the  new  diet  he  will  soon  become  dull,  and  pale,  and  flabby, 
yet  the  effects  upon  his  flesh  and  strength  are  less  notice- 
able, and  he  usually  drifts  into  rickets  before  any  appear- 
ances have  been  thought  sufficiently  serious  to  require 
medical  interference. 

Treatment. — The  treatment  of  simple  wasting  from 
insufficient  nourishment  consists  principally  in  so  selecting 
the  diet  of  the  infant,  with  due  regard  to  his  age  and 
capabilities,  that  he  may  be  able  to  digest,  and  therefore 
to  be  nourished  by,  all  the  food  he  takes.  To  do  this,  we 
must  be  thoroughly  acquainted  with  the  scale  of  diet 
suited  to  a  healthy  child  from  his  birth  onwards ;  we  are 
then  able  to  vary  this  diet  according  to  the  digestive  power 
we  find  in  our  patient.  The  weaker  the  child,  the  more 
nearly  does  his  condition  resemble  that  of  a  new-born 
infant  in  his  power  of  assimilating  different  articles  of 
food,  and  therefore  the  earlier  in  the  scale  must  we  look 
for  the  nutriment  suited  to  his  wants. 

A  short  sketch  of  this  subject  will,  then,  not  be  out  of 
place. 

The  child  ought,  if  possible,  to  be  suckled  by  his  mother, 
and  every  mother  ought  to  make  an  effort  to  perform  this 
duty.  Should  she,  however,  after  repeated  trials,  prove 
unable  to  suckle,  a  wet-nurse  must  be  provided,  or  the 
child  must  be  brought  up  by  hand.  In  choosing  a  nurse, 
attention  should  be  paid  to  two  points, — viz.,  the  state  of 
her  health  and  the  quality  of  her  milk.  With  regard  to 
her  health,  she  should  be  examined  for  signs  of  phthisis, 
scrofula,  or  syphilis ;  her  breasts  should  be  inspected,  and 
the  milk  may  be  analysed  to  determine  its  proportion  of 
proteids  and  fat.  The  best  test,  however,  is  the  condition 
of  her  child,  who  should  always  be  looked  at.  If  he  is 
healthy  and  thriving,  the  milk  is  in  all  probability  of  good 
quality ;  but  we  have  still  to  find  out  if  it  will  agree  with 
a  new  nurseling,  and  this  can  only  be  proved  by  actual  ex- 


NURSING 


31 


periment.  Much  depends  upon  the  percentage  of  proteids 
and  the  infant's  power  of  digesting  them.  In  cases  where 
the  child  shows  signs  of  discomfort  after  taking  the  breast 
or  is  subject  to  attacks  of  colicky  pain,  with  a  constipated 
state  of  the  bowels,  the  percentage  of  proteid  s  in  the  nurse's 
milk  is  probably  excessive.  It  was  noticed  by  Messrs. 
Carter  and  Richmond  that  in  most  of  the  cases  where  the 
proteids  exceeded  2*5  per  cent,  the  milk  disagreed  with  the 
infant.  -If  then,  the  first  nurse  prove  a  failure  we  must 
try  another,  and,  if  necessary,  repeat  the  change  again  and 
asrain,  for  we  cannot  rest  until  we  have  found  a  nurse  who 
is  fitted  in  every  way  to  make  the  infant  strong  and 
healthy. 

The  time  which  has  elapsed  since  the  nurse's  confine- 
ment— a  point  to  which  so  much  importance  used  to  be 
attached — matters  little  provided  she  be  not  nearing  the 
end  of  the  normal  period  of  lactation ;  for  after  the  first 
month  the  composition  of  the  breast-milk  remains  fairly 
stationary.  If  any  change  occur  it  is  rather  in  the  direc- 
tion of  a  decrease  in  the  proteids  and  ash  and  an  increase 
in  the  sugar. 

The  diet  of  a  nursing  woman  should  be  liberal :  a  certain 
amount  of  fresh  vegetables  and  fruit  should  be  included 
in  her  meals,  and  she  may  take  moderate  quantities  of 
wine  or  beer. 

Young  mothers  with  a  first  child  are  sometimes  awk- 
ward in  the  handling  of  their  charge,  and  this  is  not 
unimportant.  Infants  held  awkwardly  to  the  breast  often 
find  a  difficulty  in  retaining  the  nipple,  and  may  refuse 
the  breast  and  be  very  fretful  on  this  account.  The 
mother  should  not  hold  herself  too  erect,  but  should  bend 
over  the  child  so  as  to  allow  the  nipple  to  fall  easily  into 
his  mouth.  The  child  should  be  placed  partly  on  his 
side,  and  the  mother  should  support  the  breast  with  the 
two  first  fingers  of  her  unoccupied  hand,  so  as  to  keep  it 
steady  while  the  child  draws  the  milk.     If  the  milk  flows 


32 


INFANTILE  ATROPHY 


too  quickly  and  abundantly,  as  sometimes  happens,  it  may 
cause  vomiting  from  the  rapidity  with  which  it  has  to  be 
swallowed.  In  these  cases  she  should  be  taught  to  press 
gently  with  the  two  fingers  which  hold  the  breast,  so  as  to 
regulate  the  flow. 

The  new-born  infant  should  be  put  to  the  breast  a  few 
hours  after  birth  ;  or  as  soon  as  the  mother  has  recovered 
from  the  first  fatigues  of  labour.  This  course  has  several 
advantages:  it  ensures  the  proper  contraction  of  the 
uterus,  for  when  the  child  has  once  taken  the  breast,  no 
danger  from  after  haemorrhage  is  to  be  apprehended  ;  the 
child  has  the  benefit  of  the  thin,  watery  colostrum  which 
precedes  the  appearance  of  milk  in  the  breast,  and  acts  as 
a  gentle  laxative  upon  the  bowels,  clearing  out  the  meco- 
nium with  which  they  are  loaded ;  and  the  nipple  is  drawn 
out  while  the  breast  is  still  soft.  If  suckling  is  delayed 
until  the  secretion  of  milk  has  become  regularly  estab- 
lished, the  breast  is  apt  to  be  distended  by  its  secretion, 
so  as  almost  to  hide  the  nipple.  The  child  has  then  great 
difficulty  in  obtaining  a  hold  of  the  nipple,  and  may  besides 
suffer  much  pain  trom  the  pressure  of  his  face  against  the 
hardened  gland.  No  food  of  any  kind  should  be  given  to 
the  child  at  this  time.  The  practice  of  giving  butter  and 
sugar,  gruel,  &c.,  to  a  new-born  babe  is  a  mere  cruelty, 
and  must  be  strictly  forbidden.  The  child  should  be  put 
to  the  breast,  even  although  there  be  no  milk.  There  is 
always  more  or  less  colostrum,  which  forms  a  sufficient 
nourishment  until  the  supply  of  milk  becomes  confirmed. 
Whether  the  mother  is  afterwards  to  suckle  her  child  or 
not,  she  should  endeavour  at  any  rate  to  do  so  for  the  first 
month,  during  which  time  a  fitting  nurse  can  be  secured, 
if  a  wet  nurse  be  desired. 

The  child  should  take  the  breast  at  regular  intervals, 
every  two  hours  during  the  day  for  the  first  six  weeks ; 
and  he  should  suck  from  each  breast  alternately.  At 
night  it  is  important  that  the  mother  should  be  undis- 


NURSING 


33 


turbed ;  and  besides,  it  is  well  to  accustom  the  child  to 
quiet  during  the  hours  of  sleep.  He  should,  therefore,  be 
fed  for  the  last  time  at  11  p.m.,  and  be  then  put  to  rest  in 
a  cot  in  the  nurse's  room,  until  five  o'clock  on  the  follow- 
ing morning,  when  he  may  again  take  the  breast.  By  this 
means  the  mother  is  ensured  six  hours'  uninterrupted  sleep. 
If,  during  the  interval,  he  awakes  and  cries,  he  may  be 
pacified  by  a  small  quantity  of  condensed  milk  diluted 
with  water.  After  six  weeks,  the  interval  between  the 
meals  should  be  increased  to  three  hours,  or  even  longer,  if 
the  child  shows  no  desire  for  the  breast.  It  is  as  great  a 
mistake  to  urge  an  infant  to  take  nourishment  as  it  is .  to 
quiet  him  with  the  breast  whenever  he  cries.  The  mother 
should  be  able  to  perceive  when  her  child  cries  from 
hunger,  and  when  from  uneasiness  or  ill- temper.  If  the 
babe  rouses  himself  and  seems  pleased  at  the  sight  of  the 
mother,  clenching  his  hands,  and  flexing  his  limbs,  he  is 
hungry.  If  he  remains  passive,  he  does  not  require  the 
breast.  If  he  cries  peevishly,  has  a  hot  skin,  and  jerks 
his  lower  limbs  uneasily  about,  he  is  troubled  with  indi- 
gestion, and  the  milk  would  only  increase  his  discomfort. 

Indigestion  is  not  so  uncommon  in  infants  reared  at 
their  mother's  breast  as  might  be  supposed,  for  it  is  not 
every  mother  whose  milk  is  exactly  suited  to  her  own 
child.  If,  as  may  happen,  the  proportion  of  proteids  in 
her  milk  be  too  great  for  the  infant's  easy  digestion,  we 
find  symptoms  of  abdominal  discomfort,  if  not  actual 
colicky  pain,  after  taking  the  breast,  and  the  bowels  are 
costive  with  scanty  clay-like  stools.  In  such  cases  walk- 
ing exercise,  stopping  short  of  actual  fatigue,  should  be 
recommended  for  the  mother,  and  she  should  take  plenty 
of  farinaceous  and  vegetable  matter  with  her  meals.  By 
this  means  the  excessive  quantity  of  proteids  in  her  milk 
may  be  reduced.  I  have  also  found  it  useful  to  give  a 
few  ounces  of  plain  barley  water  from  a  feeding  bottle  to 
the  child  just  before  he  is  put  to  the  breast. 

3 


34 


INFANTILE  ATROPHY 


Up  to  tlie  age  of  six  moiitlis  tlie  breast  must  remain  the 
child's  sole  nourishment,  provided  that  the  secretion  of 
milk,  and  its  quality,  are  found  to  be  satisfactory.  If  not, 
and  the  child  wastes,  or  does  not  grow,  other  food  must 
be  given  in  addition,  as  will  be  afterwards  described. 

If  the  mother  cannot  suckle  her  infant,  and  a  wet-nurse 
is  not  desired,  the  child  must  be  "  brought  up  by  hand," 
feeding  from  a  bottle.  The  hand-feeding  of  infants  differs 
from  suckling  by  demanding  more  attention  on  the  part 
of  the  nurse,  and  some  tact  in  accurately  adapting  the 
quality  of  the  food  to  the  powers  and  requirements  of  the 
baby.  To  be  thoroughly  successful  there  are  two  points 
which  it  is  important  to  bear  continually  in  mind.  In  the 
first  place,  we  must  select  a  diet  which  not  only  contains 
in  itself  all  the  elements  of  nutrition,  but  which  also  pre- 
sents them  in  such  a  form  that  an  infant  is  able  with 
perfect  ease  to  digest  and  assimilate  them.  No  food  can 
satisfy  the  wants  of  the  infant  unless  it  contain  material 
to  supply  the  waste  of  the  nitrogenous  tissues :  therefore 
a  merely  starchy  substance,  such  as  arrowroot,  which 
enters  so  largely  into  the  diet  of  children,  especially 
amongst  the  poor,  is  a  very  undesirable  food  for  infants, 
unless  given  in  very  small  quantities,  and  mixed  largely 
with  milk.  The  second  point  to  be  remembered  is  that 
the  digestive  organs  of  an  infant  are  excessively  delicate, 
and  liable  to  be  deranged  by  apparently  trifling  causes. 
His  digestive  power  is  therefore  subject  to  frequent  varia- 
tions corresponding  accurately  to  his  state  of  health,  and 
a  diet  which  is  appropriate  one  day  may  be  unsuitable  the 
next.  Unusual  irritability  and  fretfuliiess,  abdominal 
discomfort  and  griping  pains,  vomiting  or  diarrhoea — any 
of  these  symptoms  indicates  that  the  digestive  powers  are 
for  the  time  below  par,  and  that  some  modification  of  the 
diet  is  required. 

Taking  human  milk  as  the  natural  and  most  perfect 
food  for  a  young  child,  our  object  must  be  to  make  as 


HAND-FEEDING 


35 


near  an  approach  as  possible  to  this  standard  in  the  sub- 
stitute we  proj^ose  to  adopt.  The  milk  of  some  animals, 
notably  that  of  the  ass,  resembles  women's  milk  very 
closely  ;  but  cow's  milk,  which  is  i^lentiful  and  cheap,  is 
usually  chosen,  and  when  properly  prepared  and  modified 
serves  our  purpose  well.  We  must  remember,  however, 
that  not  only  does  human  milk  differ  in  composition  from 
the  milk  of  the  cow,  but  that  it  differs  also  in  another 
point  which  it  is  important  not  to  lose  sight  of.  The 
former  is  drawn  straight  from  the  gland  pure  and  uncon- 
taminated  by  germs  ;  the  latter  has  to  pass  through  many 
hands  before  reaching  the  nursery.  The  risk  of  pollution 
is  therefore  great,  and  the  milk  is  apt  to  contain  microbes 
of  various  kinds,  some  of  which  may  be  highly  injurious. 
Attacks  of  bowel  complaints  of  great  gravity,  epidemics  of 
diphtheria  and  scarlatina,  and  tubercular  disease  with  its 
many  fatal  manifestations,  may  all  owe  their  origin  to 
impure  cow's  milk.  Our  first  care,  then,  should  be  to 
destroy  any  existing  organisms  by  heat.  A  temperature 
of  167°  Fahr.  is  said  to  be  sufiicient  for  this  purpose,  but 
I  think  it  better  to  sterilise  the  milk  in  one  of  Soxhlet's 
sterilisers,  or  at  any  rate  to  boil  it  for  twenty  minutes  in  a 
water  bath,  before  allowing  it  to  be  used.  It  is  to  be 
regretted  that  by  this  means  we  render  the  milk  less  per- 
fect as  an  antiscorbutic,  for  infantile  scurvy  may  develop 
in  hand-fed  babies  who  are  being  reared  on  boiled  or 
sterilised  milk  ;  but  this  is  a  risk  which  it  is  worth  while 
to  run  for  the  sake  of  avoiding  the  greater  evil,  especially 
as  infantile  scurvy,  if  it  begin,  can  be  easily  put  a  stop  to. 
Cow's  milk  has  a  higher  specific  gravity,  and,  as  has 
already  been  stated  (see  p.  20),  contains  a  larger  proj)or- 
tion  of  curd,  but  less  sugar  and  cream,  than  are  found  in 
human  milk.  These  differences  can  be  at  once  remedied 
by  dilution  with  water,  and  the  addition  of  cane  or  milk 
sugar  in  sufficient  quantities  to  supply  the  necessary  sweet- 
ness.   The  other  and  greater  objection  to  this  milk  con- 


36 


INFANTILE  ATROPHY 


sists  in  the  much  firmer  clot  formed  by  its  casein  when 
coagulated.  It  is  this  peculiarity  which  explains  the 
difficulty  often  found  by  infants,  especially  in  large  towns, 
in  digesting  cow's  milk,  however  diluted  it  may  be;  for 
the  addition  of  water  alone  will  not  hinder  the  firm  clot- 
ting of  the  curd.  On  this  account  methods  of  preparation 
which  merely  lessen  the  proportion  of  curd  in  cow's  milk, 
and  increase  the  proportion  of  sugar,  cannot  be  relied 
upon  to  produce  a  perfectly  satisfactory  food  for  a  young 
baby.  No  doubt  by  such  means  the  proportion  of  curd 
and  sugar  normally  existing  in  human  milk  may  be  faith- 
fully imitated ;  but  the  curd  retains  its  original  property 
of  firm  coagulation,  and  although  reduced  in  quantity  is 
not  rendered  any  the  less  difficult  of  digestion.  It  is  for 
this  reason  that  Dr.  Frankland's  plan  of  treating  cow's 
milk  is  so  often  disappointing.  By  this  method  of  pre- 
paration the  milk  is  diluted  with  a  third  part  of  whey,  and 
sugar  and  cream  are  added  in  such  quantities  as  to  imitate 
accurately  enough  the  proportion  of  casein,  sugar  and  fat 
contained  in  human  milk.  But  the  name  of  "  artificial 
human  milk"  is  not  thereby  justified,  for  the  casein, 
although  reduced  in  quantity,  is  no  easier  of  digestion 
than  it  was  before. 

Perhaps  the  closest  imitation  of  breast  milk  is  seen  in 
Gartner's  *  Mother's  Milk.'  Cow's  milk  diluted  with  an 
equal  quantity  of  sterilised  water  is  placed  in  a  rapidly 
revolving  centrifugal  separator,  which  divides  it  into  two 
parts — a  creamy  milk  and  a  skimmed  milk.  The  former 
contains  about  half  or  rather  less  of  the  casein  and  almost 
all  the  fat,  giving  a  chemical  composition  of  proteids 
1-76,  fat  3*5,  sugar  2*5,  ash  0*35.  It  therefore  only 
requires  the  addition  of  a  small  quantity  of  sugar  (about 
4  per  cent.)  to  reach  the  closest  chemical  correspondence 
with  human  milk  ;  but  there  is  still  the  difficulty  of  the 
firmness  of  the  clot.  Infants,  indeed,  often  do  as  well  upon 
this  preparation  as  they  do  upon  humanised  milk ;  but  to 


PREPARATION  OF  COw's  MILK 


37 


many  the  toughness  of  the  cnrd-clot  is  a  continual  trouble. 
It  is  this  which  is  the  great  obstacle  to  the  efficient  feeding 
of  infants.  In  order  to  make  cow's  milk  a  satisfactory 
substitute  for  the  breast  during  the  first  few  months  of 
life,  it  must  be  so  treated  that  the  casein  is  presented  in  a 
digestible  shape  to  the  infant  stomach.  This  object  may 
be  effected  in  one  of  two  ways. 

The  first  method  consists  in  adding  an  alkali,  such  as 
lime-water,  to  the  milk.  To  be  of  any  service,  however, 
the  quantity  added  must  be  considerable ;  one  or  two  tea- 
spoonfuls — the  addition  usually  made  to  a  bottleful  of 
milk  and  water — is  quite  insufficient  to  effect  the  object 
desired.  Lime-water  contains  only  half  a  grain  of  lime 
to  the  fluid  ounce ;  of  this  solution  so  small  a  quantity  as 
two  teaspoonfuls  would  be  scarcely  sufficient  to  neutralise 
the  natural  acidity  of  the  milk.  Lime-water,  no  doubt, 
acts  by  partially  neutralising  the  gastric  juice,  so  that 
clotting  of  the  curd  is  in  a  great  measure  prevented,  and 
the  milk  passes  little  changed  out  of  the  stomach,  to  be 
fully  digested  by  the  intestinal  secretions  in  the  bowels. 
To  attain  this  object  at  least  a  third  part  of  the  mixture 
should  consist  of  lime-water.  For  a  new-born  infant  two 
tablespoonfuls  of  milk  may  be  diluted  with  an  equal 
quantity  of  plain  filtered  water,  and  then  be  alkalinised 
by  two  tablespoonfuls  of  lime-water.  This  mixture,  of 
which  only  a  third  part  is  milk,  can  be  sweetened  by  the 
addition  of  a  teaspoonful  of  sugar  of  milk.  If  thought 
desirable  a  teaspoonful  of  cream  may  be  added.  The 
whole  is  then  put  into  a  perfectly  clean  feeding-bottle, 
and  is  heated  to  a  temperature  of  about  95°  Fahr.  by 
steeping  the  bottle  in  hot  water.  When  warmed,  it  is 
ready  for  use.  The  proportion  of  milk  can  be  gradually 
increased  as  the  child  gets  older. 

A  second  plan  by  which  the  casein  of  cow's  milk  can  be 
rendered  digestible  consists  in  adding  to  the  milk  a  small 
quantity  of  some  thickening  substance,  such  as  barley- 


38 


INFANTILE  ATROPHY 


water,  gelatine,  or  even  one  of  the  ordinary  farinaceous 
foods.  The  action  of  all  of  these  is  the  same,  and  is  an 
entirely  mechanical  one.  The  thickening  substance  sepa- 
rates the  particles  of  curd,  so  that  they  cannot  run  together 
into  a  solid  lump,  but  must  coagulate  separately  into 
a  multitude  of  small  masses.  By  this  means  the  curd  is 
made  artificially  to  resemble  the  naturally  light  clot  of 
human  milk,  and  is  almost  as  readily  digested  by  the 
infant. 

Although  any  thickening  matter  will  have  the  mecha- 
nical effect  desired  of  separating  the  particles  of  curd,  yet 
it  is  not  immaterial  what  substance  is  chosen.  The 
question  of  the  farinaceous  feeding  of  infants  is  a  very  im- 
portant one,  for  it  is,  as  has  been  already  remarked,  to  an 
excess  of  this  diet  that  so  many  of  their  derangements 
may  often  be  attributed.  Owing  to  a  mistaken  notion 
that  such  foods  are  peculiarly  light  and  digestible — a 
notion  so  widely  prevalent,  that  the  phrase  food  for  in- 
fants "  has  become  almost  synonymous  with  farinaceous 
matter — young  babies  are  often  fed,  as  soon  as  they  are 
born,  with  large  quantities  of  corn-flour  or  arrowroot, 
mixed  sometimes  with  milk,  but  often  with  water  alone. 
Now  starch,  of  which  all  the  farinae  so  largely  consist,  is 
digested  principally  by  the  saliva,  aided  by  the  secretion 
from  the  pancreas — two  fluids  which  convert  the  starch 
into  dextrine  and  grape  sugar  previous  to  absorption. 
But  the  amount  of  saliva  formed  in  the  new-born  infant 
is  excessively  scanty,  and  it  is  not  until  the  fourth  month 
that  the  secretion  becomes  fully  established.  Again, 
according  to  the  experiments  of  Korowin,  of  St.  Petersburg, 
the  pancreatic  juice  is  almost  absent  in  a  child  of  a  month 
old  ;  even  in  the  second  month  its  secretion  is  very  limited, 
and  has  little  action  upon  starch.  It  is  only  at  the  end  of 
the  third  month  that  its  action  upon  starch  becomes  suffi- 
ciently powerful  to  furnish  material  for  a  quantitative  exa- 
mination of  the  sugar  formed.    Therefore,  before  the  age 


infants'  foods 


39 


of  three  months  a  farinaceous  diet  is  not  to  be  recommended 
as  a  food  for  infants,  unless  the  starchy  substance  be 
given  with  great  caution,  and  in  very  small  quantities.  If 
administered  recklessly,  as  it  too  often  is,  the  food  lies  un- 
digested in  the  bowels,  ferments,  and  sets  up  a  state  of 
acid  indigestion,  which  in  so  young  and  feeble  a  being 
may  lead  to  the  most  disastrous  consequences.  In  fact, 
the  deaths  of  many  children  under  two  or  three  months 
old  can  be  often  attributed  to  no  other  cause  than  a  purely 
functional  abdominal  derangement,  excited  and  maintained 
by  too  liberal  feeding  with  farinaceous  matters.  There  is, 
however,  one  form  of  food  which,  although  farinaceous, 
is  yet  well  digested  by  even  young  infants,  if  given  in 
moderate  quantities.  This  is  barley-water.  The  starch 
it  contains  is  small  in  amount,  and  is  held  in  a  state  of 
very  fine  division.  When  barley-water*  is  mixed  with 
milk  in  equal  proportions,  it  ensures  a  fine  separation 
of  the  curd,  and  is  at  the  same  time  a  harmless  addition 
to  the  diet.  Instead  of  barley-water,  gelatine  f  may  be 
made  use  of,  and  will  be  found  to  answer  the  purpose 
well. 

Farinaceous  foods  in  general  are,  as  has  been  said, 
injurious  to  very  young  babies,  on  account  of  the  deficiency 
during  the  first  months  of  life  of  the  secretions  necessary 
for  the  conversion  of  the  starch  into  dextrine  and  grape 

*  To  prepare  the  barley-water — put  two  good  teaspoonfuls  o£  washed 
pearl  barley  with  a  pint  of  cold  water  into  a  saucepan,  and  simmer 
slowly  down  to  two  thirds.  Strain.  It  should  not  be  allowed  to  boil 
violently.  Barley-water  does  not  keep  fresh  beyond  a  few  hours.  It 
should  therefore  be  made  at  least  twice  a  day.  Once  made,  it  must 
not  be  heated  to  boiling  point  or  it  will  rapidly  turn  sour. 

t  To  prepare  gelatine — put  a  teaspoonful  of  gelatine  into  half  a 
tumbler  of  cold  water,  and  let  it  stand  for  three  hours.  Then  turn  the 
gelatine  and  water  into  a  teacup  ;  stand  this  in  a  saucepan  half  full  of 
water,  and  boil  till  the  gelatine  is  dissolved.  When  cold  this  forms  a 
jelly,  of  which  a  teaspoonful  is  to  be  added  to  half  a  bottleful  of  milk 
and  water. 


40 


INFANTILE  ATROPHY 


sugar.  If,  however,  we  can  make  such  an  addition  to  the 
food  as  will  ensure  the  necessary  chemical  change,  farina- 
ceous matter  ceases  to  be  injurious.  It  has  been  found 
that,  by  adding  to  it  malt  in  certain  proportions,  the  same 
change  is  excited  in  the  starch  artificially  as  is  produced 
naturally  by  the  salivary  and  pancreatic  secretions  during 
the  process  of  digestion.  The  employment  of  malt  for 
this  purpose  was  first  suggested  by  Mialhe,  in  a  paper 
read  before  the  French  Academy  in  1845,  and  the  sugges- 
tion was  put  into  practice  by  Liebig  fifteen  years  later. 

Many  chemists  now  prepare  malted  foods.  These  differ 
from  each  other  only  in  the  proportion  they  contain  of 
unconverted  starch.  For  the  young  infant  that  food  is 
most  suitable  in  which  the  starch  is  most  completely  con- 
verted into  dextrine.  It  is  for  this  reason  that  Mellin's 
food  is  so  valuable  a  resource.  This  food  is  found  on 
analysis  to  contain  absolutely  no  starch  at  all,  the  whole 
having  been  converted  during  its  preparation  into  dextrine 
and  glucose.  A  teaspoonful  of  Mellin's  food,  mixed  with 
milk  and  barley-water  in  equal  quantities,  is,  as  a  rule, 
readily  digested  by  the  youngest  infants.  It  very  rarely 
indeed  happens  that  it  is  found  to  disagree.  Instead  of 
malt,  pancreatine  may  be  employed  as  the  digesting  agent 
of  starch.  This  plan  has  been  adopted  with  great  success 
by  Mr.  Benger.  In  Benger's  food  the  farinaceous  meal, 
finely  ground  and  well  cooked,  is  mixed  with  pancreatine. 
When  the  food  is  added  to  warm  milk  or  milk  and  water, 
the  digestive  principle  not  only  converts  the  starch  more 
or  less  completely  into  dextrine,  but  also  acts  upon  the 
casein,  reducing  it  to  a  form  in  which  it  is  as  readily 
digestible  as  the  curd  of  human  milk.  The  food  is  a 
very  good  one,  and  usually  agrees  well. 

In  all  cases,  then,  where  a  child  is  brought  up  by  hand 
milk  should  enter  largely  into  his  diet,  and  during  the 
first  few  months  of  life  he  should  be  fed  upon  it  almost 
entirely.    We  may  begin  with  a  mixture  of  boiled  cow's 


HAND-FEEDING. 


41 


milk  diluted  with  three  or  four  times  its  bulk  of  freshly 
made  barley-water,  and  alkalised  with  lime-water  or  a 
pinch  of  bicarbonate  of  soda.  For  the  first  six  weeks  one 
to  two  ounces  of  this  food  may  be  given  at  each  meal, 
sweetened  to  taste  with  a  little  white  sugar  or  sugar  of 
milk.  As  the  child  grows  older  the  quantity  allowed 
must  be  increased,  and  at  the  same  time  the  proportion  of 
barley-water  may  be  reduced.  No  broad  rule  can  be  laid 
down  as  to  the  proportion  in  the  meals  of  the  several  con- 
stituents, for  these  must  vary  according  to  the  child's 
digestive  power.  We  must  proceed  cautiously,  making 
the  changes  step  by  step,  and  watching  the  effect  with 
care.  If  the  milk  be  not  rich,  a  little  cream  can  be  added 
with  advantage.  Instead  of  using  barley-water,  the  milk 
may  be  thickened  by  adding  to  each  quantity  of  milk  and 
water  a  teaspoonful  of  gelatine,  or  it  may  be  alkalised  with 
lime-water  as  already  described,  or  we  may  use  a  mixture 
of  milk,  barley-water,  and  lime-water  in  equal  proportions. 

When  trouble  arises  it  is,  with  most  infants,  in  the 
digestion  of  the  heavy  curd  of  cow's  milk  that  the  difficulty 
lies.  Therefore,  it  is  of  importance,  if  the  milk  seems  not 
to  agree,  to  reduce  the  quantity  of  curd  by  further  dilution 
with  freshly  made  barley-water ;  but  as  by  this  means  the 
milk  is  also  made  poorer  in  fat  and  sugar,  these  must  be 
added  afterwards  in  the  shape  of  cream  and  sugar  of  milk. 
In  America  '*milk  laboratories"^  have  been  established 
in  various  towns  by  the  energy  of  Dr.  Eotch,  and  at  his 
initiative  it  is  becoming  the  custom  for  the  physician  to 
•  prescribe  a  milk  to  contain  cream,  sugar,  and  curd  in  certain 
definite  proportions.  The  chief  advantage  of  this  practice 
lies  in  the  elaborate  precautions  adopted  to  prevent  the 
pollution  of  the  milk  by  morbific  germs,  and  in  our  know- 
ledge that  the  milk  swallowed  by  the  child  is  really  of  the 
strength  ordered.    In  other  respects  the  practice  offers 

*  A    milk  laboratory  "  of  the  kind  referred  to,  has  been  established 
in  London  by  the  Walker- Gordon  Company. 


42 


INFANTILE  ATROPHY 


little  advantage  over  the  more  homely  rule-of-thumb 
methods  prevailing  in  this  country. 

There  is  one  other  point  in  the  feeding  of  infants  which 
requires  mention,  a  point  little  regarded  as  a  rule,  but  which, 
to  my  mind,  is  one  of  extreme  importance.  I  lAean  the 
question  of  variety  in  the  feeding.  It  is  desirable  for  the 
mere  sake  of  avoiding  monotony  and  giving  help  to  the 
digestion  to  alter  from  time  to  time  the  form  in  which  the 
meal  is  giv^en  to  the  infant.  We  must  remember  that  the 
hand-fed  baby  is  being  reared  upon  a  diet  which  its  stomach 
is  not  specially  fitted  to  digest ;  which  is,  indeed,  but  a 
make-shift  in  the  absence  of  its  natural  food.  Any  help 
we  can  give  is  therefore  of  value,  and  the  useful  and  handy 
stimulus  of  variety  is  one  which  it  would  be  folly  to  make 
light  of.  The  addition  of  a  teaspoonful  of  malt  extract  or 
Mellin's  food,  by  altering  the  taste,  will  often  give  the 
spur  to  a  jaded  appetite  or  sluggish  digestion,  and  it  is 
interesting  to  note  how  quick  the  stomach  is  to  recognise 
the  change.  It  is  best  to  make  the  addition  to  each  alter- 
nate meal ;  but  sometimes  this  is  not  a  sufficient  variety, 
and  a  third  kind  of  food  has  to  be  used  in  rotation  with 
the  other  two.  I  have  even  known  cases  where  an  infant 
could  only  be  kept  well  and  thriving  by  so  arranging  the 
meals  that  no  one  of  them  was  repeated  in  quite  the  same 
shape  during  the  course  of  the  day. 

Having  fixed  upon  the  kind  of  food  which  is  suitable 
to  the  child,  we  must  next  be  careful  that  the  meals  are 
not  repeated  too  frequently.  If  the  stomach  be  kept 
constantly  overloaded,  even  with  a  digestible  diet,  the 
effect  is  almost  as  injurious  as  if  the  child  were  fed  upon 
less  digestible  food  in  more  reasonable  quantities.  A 
young  infant  passes  the  greater  part  of  his  time  asleep, 
waking  at  intervals  to  take  nourishment.  These  intervals 
must  not  be  allowed  to  be  too  short,  and  it  is  a  great  mistake 
to  accustom  a  child  to  take  food  whenever  he  cries.  After 
his  meal  the  infant  should  sleep  quietly  for  at  least  two 


HAND-FEEDING 


43 


hours.  Fretfulness  or  irritability  in  a  very  young  baby 
almost  always  indicates  indigestion  and  flatulence  ;  and  if 
a  child  cries  and  whines  uneasily,  twisting  about  his  body 
and  jerking  his  limbs,  a  fresh  meal,  although  it  may  quiet 
him  for  the  moment,  will,  after  a  short  time,  only  add  to 
his  discomfort.  During  the  first  six  weeks  or  two  months 
two  hours  will  be  a  sufficient  interval  between  the  meals. 
Afterwards  the  interval  can  be  lengthened,  and  at  the 
same  time  a  larger  quantity  may  be  given  at  each  time  of 
feeding.  No  more  food  should  be  prepared  at  one  time 
than  is  required  for  the  particular  meal.  The  position  of 
the  child  as  he  takes  food  should  be  half  reclining,  as 
when  he  is  applied  to  his  mother's  breast,  and  the  food 
should  be  given  from  a  feeding-bottle.  When  the  contents 
of  the  bottle  are  exhausted,  the  child  should  not  be 
allowed  to  continue  sucking  at  an  empty  vessel,  as  by  this 
means  air  is  swallowed,  which  may  afterwards  be  a  source 
of  great  discomfort.  The  feeding  aj)paratus  must  be  kept 
perfectly  clean.  The  boat  bottle  is  to  be  preferred,  and 
this  should  be  washed  out  after  each  meal  with  water 
containing  a  little  borate  of  soda  in  solution,  and  must 
then  lie  in  cold  water  until  again  wanted.  It  is  desirable 
to  have  two  bottles,  which  can  be  used  alternately. 

With  some  children,  in  spite  of  all  possible  precautions, 
cow's  milk,  however  carefully  it  may  be  prepared  and 
administered,  cannot  be  digested.  Soon  after  being  swal- 
lowed it  ferments,  and  either  excites  vomiting  or  produces 
great  flatulence  and  discomfort,  while  the  general  nutrition 
of  the  child  becomes  slowly  impaired.  This  incapacity  for 
digesting  cow's  milk  may  be  a  natural  peculiarity  of  the 
child,  but  more  often  it  is  a  merely  temporary  infirmity. 
In  the  former  case,  which  is  fortunately  a  rare  one,  no 
amount  of  preparation  seems  capable  of  rendering  the 
milk  digestible.  So  long  as  it  is  being  taken,  the  child 
wastes  slowly ;  he  is  restless  and  uneasy  by  day,  and 
excessively  fretful  by  night,  and  apjoears  to  be  tormented 


44 


INFANTILE  ATROPHY 


constantly  by  abdominal  pains.  In  such  cases,  if  there 
are  objections  to  a  wet  nurse,  recourse  must  be  had  to  the 
milk  of  some  other  animal ;  and  preference  should  be  given 
to  a  milk  which  contains  a  smaller  proportion  of  casein 
than  is  found  in  the  milk  of  the  cow,  such  as  goat's  or 
ass's  milk.^  Either  of  these  will  do  and  will  often  agree, 
especially  if  a  third  or  a  fourth  part  of  barley-water  be 
added;  or  a  teaspoonful  of  Mellin's  food  may  be  dissolved 
in  either  of  these  milks  diluted  with  an  equal  part  of 
water.  The  addition  of  one  or  two  teaspoonfuls  of  an 
aromatic  water,  as  dill  or  caraway- seed  f  water,  is  also  of 
service.  It  should  never  be  omitted  if  there  is  much  ten- 
dency to  flatulence.  Goat's  milk  often  has  the  strong 
flavour  peculiar  to  the  animal,  but  this  is  not  objected  to 
by  infants ;  moreover,  it  may  be  removed  to  a  certain 
extent  by  boiling.  Ass's  milk  is  sometimes  found  to  have 
slight  laxative  properties,  but  in  this  case  also  boiling  the 

*  The  relation  of  these  milks  to  each  other  and  to  human  and  cow's 
milk  is  shown  in  the  following  tahle.  The  analysis  of  the  first  three 
milks  is  from  Dr.  Frankland's  work,  "  Experimental  Researches  on 
Chemistry  " ;  that  of  goat's  milk  is  by  Mr.  A.  W.  Stokes. 


Casein. 

Butter. 

Sugar. 

Salts. 

Woman 

2-7 

3-5 

5-0 

•2 

Cow 

4-2 

3  8 

3-8 

•7 

Ass 

1-7 

1-3 

4-5 

•5 

Goat 

2-87 

5-13' 

4-69 

•87 

t  A  perfectly  useful  caraway-seed  water  may  be  made  in  the  nursery 
by  boiling  two  teaspoonfuls  of  crushed  caraway  seeds,  enclosed  in  a 
little  muslin  bag,  in  a  pint  of  water,  until  the  quantity  is  reduced  to 
one  half. 


TINNED  MILK 


45 


milk  will  often  remove  the  disadvantage.  A  milk  which 
is  very  useful  for  infants  and  others  who  cannot  digest 
ordinary  milk  is  obtained  by  re-milking  the  cow  after  the 
ordinary  daily  supply  has  been  withdrawn.  The  residuum 
thus  obtained  goes  in  some  parts  of  the  country  by  the 
name  of  strippings."  ^  It  is  very  rich  in  cream,  but 
comparatively  poor  in  curd.  One  part  of  this  diluted  with 
two  parts  of  water  will  in  almost  all  cases  agree  well ;  or 
one  part  of  milk  may  be  replaced  by  barley-water  if  there 
appears  to  be  any  difficulty  in  digesting  the  casein. 

In  cases  such  as  these,  condensed  milk  is  often  of  great 
service.  For  a  young  baby  it  should  be  diluted  with  nine 
parts  of  water,  and  it  is  well,  as  Dr.  T.  M.  Rotch  suggests, 
to  add  a  teaspoonful  of  cream  to  the  bottleful.  New- born 
babies,  as  a  rule,  do  well  upon  tinned  milks,  and  often 
thrive  upon  them  when  cow's  milk  disagrees.  I  prefer 
the  unsweetened  brands  as  less  likely  to  give  rise  to 
acidity.  Allen  and  Hanburys'  No.  1  food,  which  is  a 
desiccated  milk,  is  a  useful  form.  Still,  it  must  not  be 
forgotten  that  a  tinned  milk,  however  digestible  it  may  be, 
is  no  efficient  substitute  for  the  fresh  milk  of  the  cow. 
Children  who  are  fed  for  too  long  a  time  upon  such  foods 
often  become  rickety,  and  sometimes  develop  symptoms  of 
scurvy.  In  no  case  should  an  infant  be  allowed  to  depend 
for  nourishment  upon  preserved  milk  longer  than  is  abso- 
lutely necessary.  As  soon  as  possible  this  food  must  be 
replaced  by  fresh  cow's  milk  diluted  with  barley-water. 

In  all  cases  where  a  difficulty  is  found  in  digesting 
ordinary  cow's  milk  we  should  make  trial  of  peptonised 
milk  prepared  according  to  the  plan  of  Dr.  W.  Roberts. 

*  "  Strippings  "  or  "  af  terings  are  drawn  two  or  three  minutes  after 
the  cow  has  been  milked.  In  many  parts  it  is  the  custom  for  the 
dairy-maid  to  go  the  round  of  the  cows  after  the  milking  is  over  and 
draw  off  the  "  strippings."  The  quantity  obtained  varies  with  the 
animal;  some  cows  giving  more  than  others.  It  may  be  a  few  ounces 
or  as  much  as  half  a  pint. 


46 


INFANTILE  ATROPHY 


In  milk  so  prepared  the  curd  is  digested  by  the  action  of 
pancreatine.  An  important  drawback  to  this  method, 
when  the  ordinary  directions  are  followed  and  a  large 
quantity  is  prepared  at  one  time,  is  the  bitter  taste  given 
to  the  milk  by  the  pancreatine.  To  overcome  this  objec- 
tion I  order  each  meal  to  be  prepared  separately  in  the 
following  way  : — "  Put  the  milk,  or  milk  and  water,  into  a 
small  saucepan  and  heat  over  a  spirit-lamp.  When  the 
temperature  reaches  140°  blow  out  the  lamp  and  stir  up 
with  the  milk  a  good  pinch  of  bicarbonate  of  soda,  and 
Benger's  solution  of  pancreatine  in  the  proportion  of 
fourteen  minims  to  each  ounce  of  milk.  Let  the  pan 
stand  uncovered  for  twenty  minutes."  The  milk  is  now 
ready  for  use  and  must  be  given  at  once.  It  can  be 
sweetened  by  the  addition  of  half  a  teaspoonful  of  extract 
of  malt.  So  prepared,  the  milk  is  not  bitter,  and  will 
often  be  taken  readily  and  digested  perfectly  by  babies 
who  can  take  it  in  no  other  form. 

All  infants  are  subject  to  passing  attacks  of  gastric 
derangement  which  for  the  time  lessen  digestive  power, 
and  may  obviously  impair  nutrition.  These  disturbances 
are  the  chief  dangers  met  with  in  the  hand-feeding  of 
infants.  If  a  food  be  persisted  with  after  it  has  begun  to 
disagree,  a  catarrh  of  the  delicate  mucous  membrane  is 
certain  to  be  set  up.  When  this  happens  a  change  in  the 
diet  is  not  necessarily  followed  by  immediate  improvement. 
The  contents  of  the  stomach  swarm  with  bacteria,  and  an 
acid  fermentation  begins  which  is  likely  to  go  on  as  long 
as  fermentable  matter  continues  to  be  swallowed.  A  sour 
smell  from  the  child's  mouth  is  a  certain  sign  that  this 
fermenting  process  is  in  existence,  and  measures  should  at 
once  be  taken  to  bring  it  to  an  end.  A  reduction  in  the 
quantity  of  milk  is  an  essential  step  in  such  treatment ; 
and  if  the  case  be  a  severe  one,  and  the  fermenting  process 
active,  it  may  be  necessary,  for  a  day  or  two,  entirely  to 
exclude  milk  from  the  diet.    Its  j^lace  must  be  taken  by 


PRECAUTIONS  IN  FEEDING 


47 


mixtures  of  freshly  made  whey  and  barley-water  in  equal 
parts  ;  veal  broth  (half  a  pound  of  meat  to  the  pint)  and 
barley-water  (equal  parts),  or  Mellin's  food  dissolved  in 
whey  or  barley-water.  To  the  latter  fluids  (whey  and 
barley-water)  I  often  add  five  or  ten  drops  of  one  of  the 
cold  extracts  of  meat,  such  as  Bovinine  or  liq.  carnis,  and 
think  the  addition  a  useful  one.  After  a  day  or  two,  and 
when  all  signs  of  fermentation  have  ceased,  the  milk  may 
be  returned  to,  but  it  should  be  given  cautiously  at  the 
beginning,  and  in  small  quantities  ;  and  the  first  symptom 
of  discomfort  is  a  sign  that  the  quantity  must  be  reduced. 

In  every  case  where  milk  is  found  to  disagree,  we  should 
be  careful  to  satisfy  ourselves  that  it  is  really  the  milk 
which  is  at  fault,  and  not  its  method  of  jjreparation,  or 
the  way  in  which  it  is  given.  Too  large  a  quantity  may 
have  been  given  at  once,  or  the  meals  may  have  been  too 
frequently  repeated  ;  or  the  food,  originally  sweet,  may 
from  keeping  have  turned  sour.  The  practice  of  prepar- 
ing in  the  morning  the  whole  day's  supply  of  food  is  a 
very  dangerous  one.  It  rarely  happens,  at  the  close  of  the 
day,  that  such  food  is  fit  for  the  child's  consumption.* 
Again,  the  whole  secret  may  lie  in  a  want  of  cleanliness 
of  the  feeding  apparatus.  Amongst  the  j)oorer  classes,  so 
common  is  this  fault,  that  it  is  really  the  exception  to 
find  a  perfectly  clean  feeding-bottle,  and  a  large  propor- 
tion of  the  deaths  amongst  their  children  may  be  traced 
to  this  carelessness  alone.  Even  amongst  the  wealthier 
classes,  in  cases  where  the  direction  of  the  child's  meals 
is  left  entirely  to  servants,  the  necessary  cleanliness  is  not 
Dr.  Baginsky,  of  Berlin,  found  that  when  human  milk,  cow's  milk, 
condensed  milk  (Swiss),  two  varieties  of  farinaceous  food,  and  two 
specimens  of  prepared  infants'  food,  were  separately  exposed  for  twenty- 
four  hours  to  a  temperature  of  67°  Fahr.,  the  two  first  remained  un- 
changed, except  that  the  cow's  milk  had  become  slightly  acid.  On  the 
other  hand,  the  Swiss  milk,  the  farinaceous,  and  the  infants'  foods, 
although  apparently  fresh,  had  a  strongly  acid  reaction,  and  exhibited 
under  the  microscope  bacteria  in  active  motion. 


48 


INFANTILE  ATROPHY 


SO  common  as  could  be  wished.  The  first  care  of  the 
medical  attendant  when  called  to  a  child  brought  up  by 
hand,  should  be  to  send  for  the  feeding-bottle,  and  to 
satisfy  himself  by  his  sense  of  smell  that  it  is  fit  for  use. 

When  a  child  is  six  months  old,  farinaceous  food  may 
be  given  without  danger,  and  will  indeed  be  a  useful 
addition  to  his  diet.  The  kind  of  food  to  be  chosen  is  of 
considerable  importance,  and  in  the  selection  we  have  to 
consider  not  only  what  food  is  best  in  itself,  but  also 
what  food  is  best  digested  by  the  child.  The  same  food 
may  not  agree  equally  well  with  different  infants,  and  in 
cases  where  our  first  trial  is  unsatisfactory,  it  may  be 
necessary  to  change  the  food  several  times  before  we  have 
found  the  one  which  is  suited  to  the  particular  case. 

The  farinae  contain  nitrogenous  matter,  starch  and  salts 
in  varying  proportions,  and  those  of  them  are  best  suited 
as  food  for  infants  which  approximate  most  nearly  to 
milk,  the  natural  diet  of  the  child,  in  the  relative  propor- 
tion of  their  several  constituents.  Thus  the  relation  of 
the  nitrogenous,  or  nutritive  element  to  the  calorifiant,  is 
in  human  milk  as  one  to  four  ;  in  wheaten  flour  one  to 
five ;  in  potatoes  one  to  nine ;  in  rice  one  to  ten ;  and  in 
arrowroot,  tapioca,  and  sago,  one  to  twenty.  The  calori- 
fiant matter  exists  in  farinaceous  substances  in  the  form 
of  starch,  which  during  the  digestive  process  becomes 
converted  into  sugar  before  being  taken  up  by  the  ab- 
sorbent vessels.  But  that  this  change  should  take  place, 
it  is  important  that,  by  proper  preparation,  the  starch 
granules  should  be  brought  into  a  suitable  condition,  so 
as  to  be  readily  acted  on  by  the  digestive  organs. 

The  food  which  is  best  in  itself,  and  which  generally  is 
found  to  agree,  is  wheaten  flour.  The  best  form  in  which 
this  can  be  given  is  the  preparation  of  wheat  known  as 
''Chapman's  Entire  Wheaten  Flour."  This  is  superior 
for  the  purpose  to  the  ordinary  flour,  as  it  contains  the 
inner  husk  of  the  wheat,  finely  ground,  and  is,  therefore, 


FARINACEOUS  FOODS 


49 


rich  in  phosphates,  and  in  a  peculiar  body  called  cerealin, 
which  has  the  diastasic  property  of  changing  starchy 
matters  into  dextrine.  The  flour  is  to  be  baked  in  the 
following  way  : — A  covered  earthenware  jar  filled  with  the 
flour  is  put  into  a  slow  oven.  From  time  to  time  it  is  re- 
moved, and  the  contents  stirred  up  from  the  bottom  and 
sides  so  as  to  prevent  the  formation  of  hard  lumps.  When 
thoroughly  baked  the  flour  forms  a  soft  greyish-coloured 
powder.  A  child  of  six  months  old  will  digest  two  meals 
a  day  of  this  flour,  but  seldom  more,  and  in  many  cases  a 
single  meal  of  it  will  be  found  sufficient.  For  each  meal 
one  teaspoonful  of  the  prepared  flour  is  rubbed  up  with  a 
tablespoonful  of  cold  milk  into  a  smooth  paste.  A  second 
spoonful  of  cold  milk  is  then  added,  and  the  rubbing  is 
repeated  until  the  mixture  has  the  appearance  of  a  per- 
fectly smooth  cream.  A  quarter  of  a  pint  of  hot  milk  or 
milk  and  water  is  then  poured  upon  the  mixture,  stirring 
briskly  all  the  time,  and  the  food  is  ready  for  use.  It  may 
be  sweetened  with  extract  of  malt  instead  of  sugar. 

If  the  flour,  prepared  as  described,  be  found  not  to 
agree,  a  smaller  quantity  can  be  given,  or  some  other 
farinaceous  food  may  be  tried.  Any  of  the  so-called 
infants'  foods"  may  be  given  to  a  young  child,  and 
sometimes  one,  sometimes  another  will  be  found  to  suc- 
ceed ;  but  in  no  case  should  farinaceous  matter  ^  be 
allowed,  even  when  guarded  with  malt,  oftener  than  twice 
in  the  day.  If  there  be  much  constipation  a  teaspoonful 
of  fine  oatmeal  may  be  given  in  the  morning  instead  of 
the  flour. 

After  the  eighth  month  a  little  thin  mutton  or  chicken 
broth  or  veal  tea  may  be  given,  carefully  freed  from  all 
grease.  After  twelve  months  the  child  may  begin  to 
take  light  puddings,  well  mashed  j)otatoes  with  gravy, 

*  Most  of  the  "infants'  food"  contain  unconverted  starch.  In 
Mell.in's  food,  however,  the  whole  of  the  starch  is  digested.  This  food 
therefore,  may  be  given  without  danger  at  any  age. 

4 


60 


INFANTILE  ATROPHY 


or  tlie  lightly  boiled  yolk  of  one  egg ;  but  no  meat 
should  be  allowed  until  the  child  is  at  least  eighteen 
months  old. 

The  above  description  of  the  method  of  bringing  ujd  a 
child  by  hand  is  also  applicable  to  cases  where  the  child 
is  being  suckled  on  impoverished  milk.  In  such  cases 
the  breast  should  be  given  only  twice  a  day,  his  feeding  at 
other  times  being  conducted  according  to  the  rules  laid 
down.  A  useful  addition  to  the  breast-milk,  where  an 
addition  is  required,  during  the  first  few  weeks  of  life,  is 
a  mixture  of  cream  with  diluted  whey.  One  tablespoonf  ul 
of  fresh  cream,  with  twice  the  quantity  of  whey,  diluted 
with  two  tablespoonfuls  of  hot  water,  may  be  given  from 
a  feeding-bottle  every  three  or  four  hours.  After  a  few 
weeks  a  tablespoonful  of  milk  may  be  added,  and  this 
quantity  can  be  afterwards  gradually  increased. 

The  time  of  weaning  is  very  important.  To  deprive  a 
child  prematurely  of  the  breast  is  not  without  its  dangers, 
but  to  persist  too  long  in  nursing  is  a  fruitful  source  of 
evil.  In  ordinary  cases,  where  the  child  is  healthy,  and 
the  strength  of  the  mother  is  sufficient  for  the  task,  twelve 
months  should  be  allowed  to  elapse  before  the  child  is 
weaned.  A  longer  continuance  of  suckling  would  make 
too  great  a  demand  upon  the  strength  of  the  mother,  and 
would  be  of  no  advantage  to  the  child,  who  has  by  this 
time  become  well  accustomed  to  other  food.  It  is  some- 
times stated,  particularly  by  French  authors,  that  the 
time  of  weaning  should  be  regulated  by  the  progress  of 
dentition;  that  the  child  should  not  be  deprived  of  the 
breast  until  the  period  has  passed  during  which  the  acci- 
dents attendant  upon  dentition  may  be  expected, — which 
time  they  fix  at  the  evolution  of  the  canine  teeth.  This, 
however,  is  not  a  very  safe  guide,  as  rickets,  a  common 
result  of  mal-nutrition,  may  postpone  indefinitely  the  evo- 
lution of  the  teeth.  In  these  cases,  to  continue  the  suck- 
ling would  be  to  encourage  the  very  evil  which  it  is  our 


WEANING 


61 


principal  object  to  prevent.  The  existence  of  chronic 
disease  in  an  infant  reared  entirely  by  the  breast,  so  far 
from  being  an  impediment  to  weaning,  is,  on  the  contrary, 
the  very  strongest  argument  in  favour  of  a  change  of  diet ; 
and  the  common  objection  of  mothers  that,  on  account  of 
the  child's  weakness,  they  "  dare  not  wean  him,"  is  the 
very  worst  objection  that  could  be  possibly  urged,  and  is 
a  sufficient  proof  that  the  suckling  has  already  been  con- 
tinued far  too  long.  Human  milk  is  the  best  food  for 
infants,  not  on  account  of  any  specific  property  it  possesses, 
but  merely  because  it  is  the  most  digestible.  When,  how- 
ever, it  is  so  poor  as  to  be  no  longer  nutritious,  it  ceases  to 
rank  as  food ;  and  by  pursuing  this  course  we  fill  the 
child's  stomach  with  a  fluid  which  is  incapable  of  nourish- 
ing him,  but  which,  by  satisfying  his  appetite  for  the 
moment,  prevents  his  taking  a  meal  which  would  be  really 
beneficial. 

In  every  case  we  must  attend,  not  to  popular  prejudice, 
but  to  the  actual  condition  of  the  child.  "Wasting  in  a 
non- syphilitic  infant  shows  the  necessity  for  some  change 
in  the  diet.  But  this  change  does  not,  unless  the  child  be 
twelve  months  old,  consist  necessarily  in  weaning.  His 
condition  may  be  owing  to  a  too  liberal,  or  to  a  too  scanty, 
supply  of  food  ;  and  we  must  make  him  depend  more  upon 
the  breast-milk,  or  less  upon  that  source  of  nourishment, 
according  as  to  which  of  these  two  causes  a  history  of  his 
previous  diet  leads  us  to  attribute  his  disease. 

In  giving  additional  food  to  infants  at  the  breast,  a 
difficulty  often  arises  from  the  repugnance  of  the  child 
himself  to  this  mode  of  feeding.  Many  children,  parti- 
cularly those  who  have  been  suckled  too  frequently,  and 
to  whom  the  breast  has  been  offered  as  a  means  of  quiet- 
ing their  cries,  greatly  prefer  this  way  of  taking  nourish- 
ment to  any  other,  and  indeed  continually  refuse  it  in  any 
other  form.  In  these  cases,  should  the  mother's  milk  be 
poor  in  quality  (which  it  often  is,  although  very  abundant) 


62 


INFANTILE  ATROPHY 


it  is  bettor,  if  all  other  means  fail,  to  wean  the  child 
suddenly,  as  this  offers  the  only  plan  by  which  he  can  be 
efficiently  nourished.  This  course,  however,  should  only 
be  resorted  to  when,  in  spite  of  great  perseverance,  we  have 
not  succeeded  in  attaining  our  object.  A  little  judicious 
starvation  will  often  do  much. 

Although,  if  circumstances  allow  it,  the  child  should  be 
suckled  for  twelve  months,  yet  it  may  be  necessary  to  wean 
him  at  an  earlier  period,  thus — 

If  the  mother's  health  suffers  from  nursing ; 

If  from  some  cause,  as  pregnancy,  or  the  occurrence  of 
acute  disease,  her  milk  is  rendered  unwholesome  to  the 
child ; 

If  the  child  is  insufficiently  nourished  upon  the  breast- 
milk,  and  yet  refuses  to  take  additional  food. 

In  all  these  cases  the  ordinary  time  of  weaning  must  be 
anticipated. 

A  moment  should  be  chosen  for  weaning  when  the  child 
is  not  feverish,  nor  suffering  pain  from  the  actual  cutting 
of  a  tooth.  It  is  best  to  wean  him  gradually,  lessening  by 
degrees  the  number  of  the  times  he  is  allowed  to  take  the 
breast,  and  continuing,  for  about  a  week,  still  to  give  it  to 
him  once  a  day  ;  after  which  this,  too,  must  be  stopped. 
If  the  child  has  been  fed  as  directed,  there  is  very  little 
difficulty  about  weaning ;  he  maybe  fretful  for  a  few  days, 
and  even  refuse  his  food,  but  by  perseverance  he  becomes 
reconciled  to  his  loss. 

Children  sometimes  wean  themselves,  seeming  suddenly 
to  take  a  dislike  to  the  breast,  although  they  are  quite 
healthy  and  are  apparently  thriving  upon  the  milk.  This, 
however,  may  be  sometimes  occasioned  by  scantiness  of 
the  milk.  Usually,  when  children  refuse  the  breast,  some 
cause  may  be  discovered  by  which  the  process  of  sucking 
is  rendered  difficult  or  painful.    Thus — 

Eetraction  of  the  nipple  may  make  it  impossible  for  the 
child  to  obtain  any  milk  until  the  nipple  has  been  drawn 


CAUSES  OF  REFUSAL  OF  BREAST 


53 


out  by  a  stronger  child,  by  a  cupping-glass,  or  by  tlie 
mouth  of  the  nurse. 

Pain,  whether  from  colic,  or  earache,  or  other  cause,  will 
prevent  a  child  from  sucking  so  long  as  the  pain  is  acute 
and  distressing.  In  milder  cases  of  abdominal  discomfort, 
infants  are,  however,  often  particularly  ravenous,  as  before 
explained. 

Thrush,  or  aphthae  of  the  mouth,  may  have  the  same 
effect.  Here  the  pain  caused  by  the  moA^ements  of  the 
mouth  during  the  act  of  sucking  is  the  reason  of  the 
refusal. 

Closure  of  the  nares  from  syphilitic  swelling  and  incrus- 
tation, or  from  measles,  obliges  the  child  to  breathe  entirely 
through  the  mouth.  Here,  whenever  he  attempts  to  take 
the  breast,  a  sense  of  suffocation  compels  him  to  abandon 
the  nipple. 

In  bronchitis,  pneumonia,  and  broncho-pneumonia,  the 
child  sometimes  refuses  the  breast ;  for  there  is  laborious 
respiration,  and  both  nose  and  mouth  are  wanted  for  air- 
passages. 

In  tongue-tie  ^  and  cleft  palate,  there  is  a  mechanical 
obstacle  to  sucking,  in  the  impossibility  of  producing  the 
necessary  vacuum  in  the  mouth.  The  former  is  readily 
cured  by  snipping  the  frsenum.  The  latter  necessitates 
artificial  feeding;  but  by  an  ingenious  and  simple  con- 
trivance, designed  by  Mr.  Oakley  Coles,  the  impediment 
to  sucking  from  a  feeding-bottle  can  be  overcome,  al- 
though the  child  is  still  prevented  from  taking  the  breast. 
The  plan  consists  in  attaching  to  the  nipple  of  the 
feeding-bottle  a  flap  of  elastic  india-rubber,  cut  to  fit  the 
roof  of  the  mouth.    This  flap,  shaped  like  the  bowl  of  a 

*  By  "  tongue-tie  "  is  here  meant  those  cases  where  the  frsenum  is 
attached  to  the  whole  under-surface  of  the  tongue  as  far  as  the  tip. 
Such  cases  are  exceedingly  rare.  The  ordinary  cases  of  so-called 
tongue-tie  present  no  real  obstacle  to  sucking,  and  need  not  be  inter- 
fered with. 


54 


INFANTILE  ATllOPHY 


teaspoon,  is  cut  out  of  thin  sheet  elastic,  and  is  sewn  to 
the  upper  part  of  the  stalk  of  the  nipple  where  this 
projects  from  the  shield.  In  the  mouth  of  the  infant 
the  flap  forms  an  artificial  palate,  against  which  the 
nipple  is  pressed  during  suction,  and  the  fluid  is  thus 
prevented  from  passing  into  the  nose  in  the  act  of  swal- 
lowing. 

Infants  who  have  been  brought  up  at  the  breast  with- 
out the  addition  of  any  other  food  are  sometimes  difficult 
to  wean,  as  the  new  food  does  not  always  agree.  Accus- 
tomed as  such  children  are  to  the  light  human  milk,  the 
firm  curd  of  cow's  milk  proves  a  heavy  tax  upon  their 
digestive  powers,  and  unless  the  change  be  made  with  care 
serious  dangers  may  arise.  In  these  cases  the  milk  should 
be  diluted  with  barley-water,  or  thickened  with  some 
infants'  food. 

When  the  child  has  become  accustomed  to  do  without 
the  breast-milk,  he  may  begin  to  take  the  food  which  is 
hereafter  to  form  his  ordinary  diet.  Potatoes  carefully 
mashed  with  a  spoon,  with  gravy ;  meat  broths  ;  light 
puddings ;  eggs  very  lightly  boiled  ;  or  a  bone  to  suck, 
may  be  allowed.  No  meat,  however,  should  be  given  till 
the  sixteenth  or  eighteenth  month,  when  he  may  begin 
with  a  very  small  quantity  once  in  the  day.  The  best  kind 
is  a  small  j)iece  of  roast  mutton,  without  any  fat  or  grease. 
This  should  be  very  finely  minced,  or  even  pounded  in  a 
mortar  to  ensure  fine  division,  for  a  young  child  will  not 
chew  his  food.  With  this  he  may  drink  plain  water,  toast- 
water,  or  milk-and-water. 

For  further  information  on  the  subject  of  feeding  chil- 
dren, see  Chap.  XI,  Diets  1 — 11. 

In  making  the  various  changes  in  the  diet,  it  is  im- 
portant to  watch  the  child  carefully,  so  that  too  great 
precipitancy  may  be  avoided.  Any  signs  of  laboured 
digestion  should  be  carefully  noted,  and  a  simpler  diet 
at  once  returned  to.    The  child  when  awake  should  be 


BATHING  AND  HYGIENE 


55 


active  and  cheerful,  and  his  sleep  should  be  tranquil  and 
undisturbed. 

While  attention  is  thus  paid  to  diet,  all  the  other  pre- 
cautions, indispensable  to  perfect  health,  should  be  ob- 
served. 

Cleanliness  must  be  attended  to,  but  every  care  must  be 
taken  ,  not  to  chill  the  child  by  dawdling  over  his  bath. 
The  water  used  should  be  hot  (95°  to  100°  Fahr.),  and  the 
process  must  be  a  rapid  one,  soaping  the  child  quickly  all 
over  the  body,  and  then  sponging  off  the  lather  without 
loss  of  time,  while  he  sits  in  the  hot  water.  He  must  not 
be  allowed  to  play  in  the  water  or  wait  in  the  bath  wet  and 
evaporating,  while  the  nurse  busies  herself  with  other 
matters,  but  must  be  lifted  out  at  once,  wrapj^ed  in  a  warm 
towel,  and  dried  without  undue  exposure.  In  the  case  of 
very  susceptible  children  it  is  advisable  instead  of  soaping 
the  child  in  the  usual  way,  to  put  him  into  hot  soap-suds 
and  sponge  him  quickly  with  the  lather.  Diapers,  when 
soiled,  must  be  changed  at  once  and  taken  out  of  the 
nursery ;  and  after  each  action  of  the  bowels  the  nates 
should  be  sponged  with  warm  water  and  carefully  dried. 
The  nurseries  should  be  large  and  well  ventilated,  and 
ought  not  to  be  in  the  neighbourhood  of  an  open  drain-pipe, 
however  carefully  this  may  be  trapped  or  cut  off  from  the 
sewer.  Water-closets  and  housemaids'  sinks  just  outside 
the  nursery  are  a  fruitful  source  of  danger.  The  day- room 
must  be  kept  as  nearly  as  may  be  at  a  temperature  of  65^ 
Fahr.,  and  if  possible  should  face  the  south,  as  sunlight  is 
of  great  importance.  The  child  should  sleep  by  himself  in 
a  cot  without  curtains,  not  in  the  same  bed  with  his  nurse, 
and  every  means  must  be  taken  to  keep  the  air  about  him 
fresh  and  pure.  Whenever  the  weather  permits  he  should 
be  taken  out.  His  outdoor  dress  should  be  warm,  his  legs 
should  be  well  covered  up,  and  as  a  further  protection 
against  the  cold  he  should  wear  a  flannel  bandage  round 
the  belly. 


56 


INFANTILE  ATROPHY 


From  the  sketch  given  in  the  preceding  pages  of  the 
scale  of  diet  suited  to  a  healthy  child,  it  is  easy  so  to 
arrange  the  number  and  quality  of  his  meals  that  a  suffi- 
cient amount  of  nourishment  may  be  given  without  over- 
tasking its  digestive  powers.  When  the  diet  has  been 
properly  regulated,  the  child  is  found  rapidly  to  regain 
flesh,  his  peevishness  and  irritability  disappear,  and  his 
health  returns.  Any  digestive  derangement  which  may 
occur  should  be  at  once  attended  to,  and,  as  this  is  usually 
due  to  some  deviation  from  the  prescribed  rules,  a  return  to 
the  proper  diet  will  generally  cause  it  quickly  to  disappear, 
especially  if  a  gentle  laxative  be  given  at  the  same  time. 

The  constipation  which  is  so  common  a  result  of  im- 
proper food,  often  continues  after  the  change  of  diet. 
In  these  cases  if  the  child  be  at  the  breast,  the  mother  may 
take  an  occasional  saline  aperient,  and  increase  the  quan- 
tity of  fresh  vegetables  to  her  meals.  Should  this  plan 
fail  in  relieving  the  child,  a  teaspoonf ul  of  castor  oil  can  be 
given  him ;  or  a  few  grains  of  magnesia  may  be  adminis- 
tered, with  syrup  of  ginger,  in  some  aromatic  water ;  or  a 
little  manna  may  be  dissolved  in  hot  water,  strained  and 
added  to  the  food  in  the  bottle.  If,  after  repeated  attempts, 
we  find  that  a  daily  action  of  the  bowels  cannot  be  ob- 
tained, without  a  daily  repetition  of  the  aperient,  it  is  use- 
ful to  give  small  doses  of  senna  combined  with  a  bitter 
tonic.  Thus  a  third  part  of  infusion  of  senna  may  be 
added  to  two-thirds  of  the  compound  infusion  of  gentian. 
Of  this  mixture  a  teaspoonful  given  two  or  three  times  a 
day  will  soon  regulate  the  bowels,  so  that  after  a  time  the 
medicine  can  be  gradually  discontinued.  The  value  of  this 
remedy  is  increased  by  the  addition  of  five  drops  of  tinc- 
ture of  belladonna  and  a  quarter  of  a  drop  of  tincture  of 
nux  vomica. 

In  cases  where  the  constipation  is  very  obstinate ;  where 
hard  clay- coloured  motions,  often  mottled  with  streaks  of 
green,  are  passed  at  rare  intervals,  with  violent  and  painful 


APERIENTS 


57 


expulsive  efforts,  two,  three,  or  more  drops  of  a  solution 
containing  one  grain  of  podophyllin  in  a  drachm  of  alcohol 
may  be  given  to  the  infant  in  a  little  glycerine  every  night. 
This  treatment  restores  the  natural  colour  to  the  motions, 
removes  the  abnormal  distension,  and  eases  the  colic.  A 
less  disagreeable  remedy  is  sulphur.  Curiously  small 
doses  of  this  drug  will  prove  effectual  if  given  regularly. 
In  the  case  of  most  children  half  a  grain  given  every  night 
at  bedtime  will  produce  a  regular  action  of  the  bowels. 
Another  useful  drug  is  the  liquid  extract  of  Cascara 
Sagrada.  Like  the  others,  this  remedy  is  best  given  in 
one  dose  at  bedtime.  A  young  baby  may  begin  with  five 
drops  in  a  teaspoonful  of  water  sweetened  with  an  equal 
quantity  of  extract  of  malt.  If  this  dose  does  not  produce 
a  sufficient  movement,  it  can  be  increased  every  night  by 
one  drop  until  the  desired  result  is  attained.  The  saline 
aperients  are  favourite  remedies  with  some  practitioners, 
but  these  salts  should  not  be  used  indiscriminately.  They 
are  especially  indicated  in  cases  where  the  stools  are  habi- 
tually dry.  When  constipation  results  from  this  lack  of 
moisture  a  few  grains  of  the  sulphate  or  carbonate  of 
magnesia  given  two  or  three  times  a  day  will  soon  induce 
copious  relief.  Afterwards,  one  dose  administered  every 
evening  will  usually  keep  up  a  sufficient  action  of  the 
bowels. 

Enemas  should  only  be  used  when  the  constipation  is 
obstinate  with  great  accumulation  in  the  bowels,  and  then 
only  as  a  temporary  measure.  They  may  be  given  either 
alone,  or  as  an  aid  to  the  action  of  purgatives  taken  by 
the  mouth.  Two  or  three  drachms  of  castor  oil,  with  six 
or  eight  ounces  of  thin,  warm  gruel,  may  be  used  for  a 
child  of  twelve  months  old.  In  using  injections,  the  tube 
must  be  well  oiled,  and  must  be  very  carefully  introduced, 
remembering  that  the  bowel  inclines  gradually  to  the  left 
side.    The  fluid  should  be  thrown  up  with  moderate  force. 

Other  means  of  obtaining  a  satisfactory  movement  of 


58 


INFANTILE  ATROPHY 


the  bowels  consist  in  the  use  of  suppositories  of  castile 
soap  or  glyco-gelatine,  and  in  frictions  over  the  belly  with 
a  stimulating  liniment.  The  addition  of  aloes  to  the  lini- 
ment is  said  to  render  the  effects  of  the  application  more 
decided  ;  thus,  half  an  ounce  of  the  compound  tincture  of 
aloes  combined  with  twice  the  quantity  of  compound  soap 
liniment  forms  a  useful  embrocation  for  this  purpose. 
It  may  be  rubbed  into  the  belly  every  morning.  Probably 
the  value  of  this  mode  of  treatment  lies  not  so  much  in 
the  liniment  as  in  the  friction.  Methodical  kneading  of 
the  abdomen  has  long  been  recognised  as  a  useful  remedy 
ill  case  of  habitual  constipation.  But  the  rubbing  to  be 
effectual  must  be  employed  systematically.  It  should 
consist  of  firm  pressure  with  the  thumbs  carried  round 
the  belly  in  the  course  of  the  large  intestine,  varied  occa- 
sionally by  circular  friction  round  the  umbilicus  with  the 
palm  of  the  hand.  Such  manipulation  carried  out  ener- 
getically (but  not  violently)  every  morning,  for  five  or 
more  minutes  after  the  bath,  will  often  induce  regularity 
of  action  in  a  surprisingly  short  time. 

In  children  who  suffer  from  habitual  constipation,  care 
should  be  taken  to  keep  the  body  and  limbs  perfectly  warm. 
A  warm  bath  will  often  produce  an  action  of  the  bowels 
when  aperients  have  been  given  without  any  effect.  If 
the  child  be  old  enough  to  take  farinaceous  food,  a 
morning  meal  of  milk  thickened  with  a  teaspooiiful  of  fine 
oatmeal  will  often  render  the  administration  of  drugs 
unnecessary. 

Rhubarb  should  not  be  used  as  an  aperient  for  children 
where  the  constipation  is  obstinate,  unless  combined  with 
jalap  or  scammony,  or  some  other  purgative,  on  account 
of  its  after-astringent  effects ;  but  for  the  same  reason  it 
is  extremely  valuable  in  the  looseness  of  the  bowels  which 
is  the  result  of  acidity.  Acidity  is  produced  by  fermenta- 
tion of  the  food  in  the  alimentary  canal,  and  gives  rise  to 
much  flatulence,  shown  by  sour- smelling  eructations,  and 


TREATMENT 


59 


griping  pains  in  the  belly.  In  these  cases  the  feeding 
apparatus  should  always  be  examined.  A  want  of  cleanli- 
ness in  the  bottle  is  a  common  cause  of  this  teasing  de- 
rangement. If  the  griping  is  accompanied  by  constipation, 
the  bowels  should  be  opened  by  a  gentle  purge,  as  mag- 
nesia and  senna,  or  castor  oil,  after  which  the  following 
mixture  may  be  ordered  : — 

Sodse  Bicarb.,  gr.  iij, 
Tinct.  Nucis  Vomica),  gutta  ^, 
Tinct.  Card.  Co.,  mv, 
Sp.  Chloroform.,  mj ; 
Aq.  ad  5].    M.    Ft.  haustus. 
To  be  taken  every  six  hours. 

Aromatics  are  very  useful  in  these  cases,  and  indeed 
should  always  be  included  in  mixtures  for  children  wherever 
there  are  any  signs  of  intestinal  irritation. 

The  following  case  well  illustrates  the  value  of  alkalies 
and  aromatics,  conjoined  with  a  regulated  diet,  in  the 
treatment  of  simple  atrophy  accompanied  by  constipation 
and  flatulence. 

George  M — ,  aged  two  months,  has  been  pining  away 
ever  since  birth.  Is  not  half  the  size  he  was."  Does 
not  cry  loudly,  but  "  frets  and  pines."  Is  suckled,  but  the 
mother  has  very  little  milk ;  is  therefore  fed  besides  on 
sago  and  corn-flour  made  with  water. 

Child  is  bright-looking,  but  very  small  and  thin.  Fon- 
tanelle  depressed.  Lips  rather  pale.  Nasal  furrow  not 
marked.  Tongue  clean,  colour  of  rust  of  iron.  Skin 
cool,  not  rough  or  harsh ;  a  little  eczema  about  folds  of 
groin.  Anus  a  little  red,  but  no  cracks  or  fissures  there. 
Does  not  snuffle.  Is  not  sick.  Bowels  act  once  or  twice 
a  day.  Motions  in  little  light-coloured  lumps  with  mucus, 
not  offensive,  passed  with  some  straining.  Moves  legs 
uneasily,  as  if  griped. 

Was  ordered  to  be  fed  on  milk  and  lime-water,  in  equal 
proportions,  given  every  three  hours.    No  other  food  ex- 


60 


INFANTILE  ATROPHY 


cept  breast-inilk.  A  flannel  bandage  to  be  applied  round 
the  belly.  The  following  draught  to  be  given  three  times 
a  day : — 

]Ji    Sodae  Bicarb.,  gr.  iij, 
8p.  Chloroform i,  mj, 
Aq.  Mentha)  Piper.,  ty\x, 
Aquam  ad  5j.    M.    Ft.  haustus. 

At  the  next  visit,  a  week  afterwards  : — Continues  to 
waste.  Sometimes  refuses  the  bottle  and  the  breast,  a,])- 
parently  from  the  pains  in  belly.  Belly  very  hard ;  child 
wrinkles  forehead,  draws  up  the  corners  of  his  lips,  and 
flexes  thighs  on  abdomen.  Bowels  open  twice  a  day  with 
straining.  Motions  light  coloured,  solid,  and  smell  sour  ; 
no  mucus.  Feet  examined,  and  found  to  be  very  cold. 
Tongue  clean. 

Feet  and  legs  to  be  warmly  covered  up.  The  milk  and 
lime-water  to  be  continued. 

1^    Pulv.  Rha^i, 

Soda3  Bicarb.,  aa  gr.  iij  ft.  pulv. 

To  be  taken  at  once . 
Bismuthi  Carb.,  gr.  ij, 
Pulv.  Cretse  Aromat.,  gr.  iij, 
Glycerine,  luv, 
Mucilaginis,  rrtx, 
Aquam  ad  5j.    Ft.  haustus. 
To  be  taken  three  times  a  di\y. 

On  the  following  week  : — Child  very  much  better  ;  is 
beginning  to  gain  flesh.  Motions  still  light  coloured  and 
rather  firm,  two  in  the  day.  Still  rather  flatulent ;  turns 
"  deadly  white  "  at  times  (when  violently  griped). 

To  continue  the  same  diet.  Half  a  drop  of  Tinct. 
Capsici  added  to  each  dose  of  the  mixture. 

After  this  the  flatulence  ceased ;  the  motions  became 
natural ;  and  the  child  rapidly  became  fat  and  well. 

If  the  bowels,  instead  of  being  confined,  are  rather 
loose,  with  dark,  slimy,  offensive  stools,  a  dose  of  powdered 
rhubarb  and  magnesia,  three  grains  of  each,  should  be 


FLATULENCE 


61 


given,  and  maybe  followed  by  the  above  mixture,  with  the 
addition  of  half  a  drop  of  laudanum  to  each  dose  ;  or  the 
following  may  be  given  : — 

^    Tinct.  Opii,  rrtss, 
01.  Ricini,  miij, 
Glycerini,  inv, 
Mucilag.  Acaciffi,  irtv. 
Aq.  ad  5j.    M.    Ft.  haustus. 
To  be  taken  three  times  a  day. 

This  combination  of  castor  oil  with  laudanum  is  especi- 
ally valuable  in  the  screaming  fits  to  which  badly-fed 
children  are  so  liable.  If  there  is  a  sour  smell  from  the 
breath,  a  few  grains  of  prepared  chalk  may  be  substituted 
in  each  dose  for  the  castor  oil.  At  the  same  time  all  fari- 
naceous foods  should  be  suspended  for  a  day  or  two,  and 
the  diet  be  limited  to  milk  and  lime-water,  or  barley-water 
and  milk.  In  all  these  cases  of  abdominal  pain,  the  feet 
should  be  examined,  for  cold  feet  alone  may  be  the  cause 
of  the  griping.  Chafing  and  warming  the  feet  often  stop 
a  baby's  cries ;  and  in  the  screaming  fits  "  the  soothing 
influence  of  gentle  friction  is  very  decided.  Rubbing  the 
body  gently  with  the  open  hand  quiets  the  child  almost  at 
once. 

If  a  return  to  the  ordinary  food  is  followed  by  the  same 
flatulent  condition,  and  this  happens  several  times  in  suc- 
cession, the  diet  evidently  does  not  agree  with  the  child, 
and  some  alteration  is  required.  Trials  should  be  made 
of  different  kinds  of  foods,  for,  as  already  explained,  the 
same  food  is  not  suited  to  every  case.  A  malted  food — 
especially  Mellin's  infants'  food — is  a  great  resource  under 
such  circumstances.  Sometimes  it  is  the  milk  which  dis- 
agrees, and  we  are  forced  to  discontinue  it  altogether, 
giving  instead  beef,  veal,  or  mutton  broth,  thickened  with 
some  farinaceous  food.  Often,  however,  it  is  due  to  mono- 
tony of  diet,  and  more  variety  should  be  introduced  into 
the  feeding  (see  Chap.  XI,  Diets  15,  16,  and  17).  When 


62 


INFANTILE  ATROPHY 


the  flatulence  is  obstinate,  frictions  with  a  stimulating 
liniment  should  be  employed  daily  to  the  belly,  the 
flannel  bandage  being  removed  for  the  purpose,  and 
afterwards  replaced.  At  the  same  time  a  mixture  con- 
taining infusion  of  rhubarb,  with  a  little  tincture  of 
myrrh,  may  be  given  twice  or  three  times  in  the  day,  to 
give  tone  to  the  bowels,  and  increase  their  peristaltic 
action : — 

p.    Infusi  Rhaei,  Tn.x, 
Syrupi  Zingib.,  rav, 
Tinct.  Myrrhse,  mj, 

Aq.  Menth.  Pip.  ad  5j.    M.    Ft.  liaustus. 
To  be  takeu  two  or  three  times  a  day. 

If  sickness  accompanies  the  flatulence,  a  teaspoonful  of 
ipecacuanha  wine  should  be  given  to  relieve  the  stomach ; 
after  which  a  mixture  containing  bismuth  and  soda  may 
be  ordered : — 

Bismuthi  Carb.,  gr.  iij, 
SodsB  Bicarb.,  gr.  ij, 
Glycerini,  inv, 
Mucilag.  Tragacanth,  rrtx, 
Aquam  ad  5j.    M.    Ft.  haustus. 
To  be  taken  three  times  a  day. 

Or  the  mixture  containing  bicarbonate  of  soda  with  spirits 
of  chloroform  (see  p.  59)  may  be  used. 

For  ordinary  attacks  of  colic.  Dr.  Boyd  recommends  ten 
drops  of  Sp.  ^theris  Nitrosi  in  a  drachm  of  water.  He 
states  that  a  few  minutes  after  this  draught  has  been  given 
a  discharge  of  flatus  takes  place,  followed  by  the  passage 
of  a  large  quantity  of  urine,  and  the  distress  of  the  child 
is  at  an  end.  But  in  some  of  these  cases  (and  usually  in 
those  in  which  the  pain  is  most  severe)  the  colic  is  not 
easily  controlled  by  antispasmodic  remedies.  Where  this 
is  the  case  I  have  found  great  benefit  from  Finkler's 
papain  given  in  doses  of  one  or  two  grains  with  an  equal 
quantity  of  bicarbonate  of  soda  with  each  of  the  meals. 


COLIC 


63 


When  the  colic  is  very  severe,  great  alarm  may  be 
excited  by  the  state  of  apparent  collapse  into  which  the 
infant  is  thrown.  The  child  should  be  placed  in  a  hot 
bath  (100°  Fahr.)  ;  the  bowels  should  be  relieved  by  an 
injection  of  warm  water  ;  and  a  few  drops  of  brandy  or  sal 
volatile  should  be  given  in  milk  or  water.  On  being 
removed  from  the  bath,  the  child  must  be  carefully  dried  ; 
a  hot  linseed  meal  poultice,  on  which  ten  or  fifteen  drops 
of  laudanum  have  been  sprinkled,  should  be  applied  to  the 
belly  ;  and  he  should  be  then  wrapped  up  in  warm  flannel. 
If  the  fontanelle  remain  depressed,  the  brandy  may  be 
repeated,  and  a  mixture  containing  codeia  with  sal  vola- 
tile, spirits  of  chloroform  and  a  little  bicarbonate  of  soda 
may  be  prescribed  : — 

P>    CodeijB,  gr.  3^, 

Sodae  Bicarb.,  gr.  ij, 
Sp.  Ammon.  Aromat., 
Sp.  Chloroformi,  aa  nij, 
Aq.  Anethi  ad  5j.    M.    Ft.  liaustus. 
To  be  taken  every  three  hours. 

Convulsions  may  arise  from  this  condition  of  the  bowels, 
and  can  be  treated  in  the  same  way.  If,  however,  they 
continue,  and  are  not  relieved  by  the  measures  adopted, 
turpentine  may  be  given,  as  recommended  by  Dr. 
Graves : — 

Jt.    01.  Terebinth! noe,  inj, 
01.  Ricini,  luiij, 
Glycerini,  irtv, 
Mucilaginis  AcacijB,  rn.v, 
Aq.  Menth.  Pip.  ad  5j.    M.    Ft.  haustus. 
To  be  taken  every  three  hours. 

This  acts  on  the  bowels,  and  produces  a  copious  discharge 
of  urine.  On  recovery,  great  attention  should  be  paid  to 
the  diet  and  bowels,  that  the  symptoms  may  not  return. 

Thrush  is  readily  cured  by  attention  to  cleanliness.  It 
should  be .  made  a  rule  always  to  wash  out  the  child's 


64 


INFANTILE  ATROPHY 


mouth  immediately  after  a  meal,  to  prevent  any  accumu- 
lation of  food  or  milk  round  the  gums.  This  is  readily 
done  with  a  good- sized  camePs-hair  brush,  or  a  piece  of 
linen  rag  dipped  into  warm  water.  Attention  to  this 
point  will  prevent  the  appearance  of  thrush,  especially  if 
care  be  taken  that  the  nipple  of  the  mother  is  perfectly 
clean.  When  thrush  has  appeared,  an  aperient  should  be 
given,  composed  of  one  grain  of  grey  powder  and  two  or 
three  of  powdered  rhubarb.  The  mother  should  be 
directed  to  cleanse  the  child's  mouth  frequently  with  warm 
water,  and  afterwards  to  apply  a  solution  of  borax  in  water 
sweetened  with  glycerine  (5ss.  to  3])  with  a  soft  brush. 
If  at  the  same  time  the  following  draught  be  given  every 
four  hours,  the  thrush,  even  although  extensive,  usually 
clears  away  completely  in  a  couple  of  days. 

^    Glycerin!  Acidi  Carbolici, 
Tinct.  lodi  aa,  mss, 
Glycerini,  inv, 

Aquam  ad  5j.    M.    Ft.  liaustus. 

If  aphthae  form,  the  same  attention  should  be  paid  to 
cleanliness ;  a  powder  of  rhubarb  and  jalap,  with  a  grain 
of  Hydrargyrum  cum  Creta,  should  be  be  given  to  evacuate 
the  bowels ;  after  which  the  following  mixture  may  be 
prescribed : — 

Soda?  Chloratis,  gr.  iij, 

Acidi  Hydroclilorici  Diluti,  mj, 

Glycerini,  mv, 

Aquam  ad  5j.    M.    Ft.  baustus. 
To  be  taken  every  four  hours. 

When  attacks  of  acute  indigestion  come  on,  with  hot 
skin,  furred  tongue,  thirst,  vomiting,  and  diarrhoea,  accom- 
panied by  griping  pain,  all  food  must  be  stopped,  and 
nothing  be  allowed  but  cold  barley-water.  The  stomach 
should  be  relieved  by  an  emetic  of  ipecacuanha,  after  the 
action  of  which  a  purgative  of  rhubarb  and  magnesia 
should  be  given  to  clear  out  irritating  matters  from  the 


DIARRHCEA 


65 


bowels.  A  mixture  of  tincture  of  catechu  with  aromatic 
confection  can  then  be  given,  or  the  following : — 

Zinci  Oxidi,  gr.  j, 

Pulv.  Cret£B  Aromat.j  gr.  ij, 

Glycerini,  ntv, 

Aq.  Chloroformi  ad  53«    M.    Ft.  haustus. 
To  be  taken  three  times  a  day. 

If  the  diarrhoea  continues  after  the  tongue  has  become 
clean,  half  a  drop  of  laudanum  can  be  added  to  each  dose 
of  either  of  these  mixtures,  or  a  few  drops  of  tincture  of 
rhubarb  may  be  given  with  half  a  drop  of  laudanum  and 
a  drop  of  sal  volatile  in  an  aromatic  water.  When  the  irri- 
tability of  the  stomach  has  subsided,  milk  and  barley-water 
may  be  resumed,  but  with  caution,  lest  the  vomiting 
return ;  and,  after  subsidence  of  the  fever,  great  prudence 
should  be  exercised  in  returning  to  the  ordinary  diet. 


S 


CHAPTER  II 


CHRONIC  DIARRHCEA 

(CflRONIC  INTESTINAL  CATARRH) 

CHRONIC  diarrhoea  is  a  fairly  common  derangement  in 
childhood,  and  often  ends  fatally.  During  the  first 
two  years  of  life  a  diarrhoea,  when  it  becomes  established, 
is  very  difficult  to  arrest,  and  even  when  the  looseness  of 
the  bowels  has  been  checked,  many  weeks  of  care  may  still 
be  required  to  restore  the  alimentary  canal  to  a  healthy 
condition.  In  older  children  chronic  diarrhoea  is  a  less 
fatal  disease,  but  it  often  lasts  for  months  together,  and  by 
the  interference  with  nutrition  it  occasions,  may  lead  to 
very  serious  consequences. 

Chronic  diarrhoea  may  either  occur  as  the  sequel  of  an 
acute  attack  or  may  begin  insidiously. 

In  the  former  case  it  is  often  secondary  to  some  acute 
disease,  as  measles  or  scarlatina ;  the  exanthem  being 
accompanied  by  a  looseness  of  the  bowels,  which  persists 
after  the  disease  which  originated  it  has  passed  away. 
Or  it  may  begin  as  an  attack  of  acute  catarrhal  diarrhoea, 
with  fever,  abdominal  pains,  and  perhaps  vomiting.  This 
attack  subsides  for  a  time,  but  returns  again  and  again 
until  the  chronic  disease  becomes  established.  This  form 
of  beginning  is,  perhaps,  more  common  after  the  period  of 
infancy  has  passed  by  ;  but  it  is  occasionally  seen  in  quite 
young  children. 

The  insidious  beginning  is  met  with  most  frequently 
during  the  second  year  of  life.    This  form  of  the  derange- 


CHARACTER  OF  THE  STOOLS. 


67 


ment  is  one  which  it  is  very  important  to  recognise  early, 
for  if  promptly  treated  it  readily  yields,  but  if  allowed  to 
continue,  becomes  very  obstinate  and  difficult  of  cure. 
There  is  no  fever,  and  at  first  no  actual  diarrhoea.  The 
stools  are  not  very  numerous,  numbering  only  two,  three^ 
or  four  in  a  day — perhaps,  even,  only  one  in  the  twenty- 
four  hours.  They  are  pale,  often  of  the  colour  and  con- 
sistence of  soft  putty,  and  are  sometimes  evacuated  with 
straining.  The  dejections  may  be  preceded  by  some  pain 
in  the  belly.  At  this  stage  the  disease  seems  to  consist 
mainly  in  increased  peristaltic  action  of  the  intestines 
forcing  along  their  contents  too  rapidly  to  allow  of 
efficient  digestion  being  performed.  The  motions  are 
copious,  and  consist  of  curds  and  farinaceous  matter 
from  the  milk  and  food  which  has  been  swallowed,  mixed 
with  some  half -liquid  faeces  and,  if  there  be  much  strain- 
ing, with  mucus  and  blood.  The  blood  at  this  time  is  in 
the  form  of  red  streaks,  and  results  from  the  rupture  of 
small  vessels  about  the  anus  in  the  act  of  straining.  In 
such  a  form  it  is  a  common  accompaniment  of  diarrhoea 
in  children  where  there  is  much  tenesmus.  The  stools 
have  often  an  offensive  sour  smell.  The  child  looks  rather 
dispirited  and  dull.  His  complexion  is  pale,  with  a  muddy 
or  sallow  tint,  and  his  feet  are  habitually  cold.  Still,  he 
is  fairly  lively,  and  takes  his  food  with  appetite. 

This  state  of  things  may  continue  for  a  considerable 
time,  often  for  several  weeks,  or  even  months.  The  child 
gradually  loses  flesh,  and  becomes  paler  and  more  languid  ; 
but  there  is  no  actual  diarrhoea.  The  nurses  on  being 
questioned,  will  say  that  the  bowels  are  nicely  open,"  and 
it  often  requires  careful  cross-examination  of  the  attendant 
to  discover  the  cause  of  the  loss  of  flesh.  In  these  cases, 
therefore,  it  is  important  to  inspect  the  evacuations. 

After  a  time  the  stools  become  more  frequent  and  more 
liquid;  but  vary  considerably  in  appearance  from  day  to 
day.    At  one  time  they  are  thin,  watery,  and  brownish. 


68 


CHRONIC  DIARRHCEA 


like  dirty  water ;  at  others,  thicker  and  clay-coloured,  like 
thin  mud ;  they  frequently  contain  mucus,  free,  or  mixed 
with  a  grumous  matter,  when  they  are  called  "  slimy  "  by 
nurses,  and  almost  always  present  little  masses  of  undi- 
gested food.  Occasionally  they  contain  particles  of  grass- 
green  matter,  from  altered  bile  or  blood,  in  the  latter  case 
an  indication  of  some  additional  irritation  of  the  bowel. 
The  smell  becomes  more  and  more  unpleasant,  and  the 
stools  sometimes  have  a  putrid  odour  which  is  inexj^ressibly 
offensive. 

When  the  diarrhoea  is  regularly  established,  the  tendency 
of  the  stools  is  to  become  more  and  more  liquid,  and  less 
and  less  homogeneous ;  but  there  is  no  regular  progression 
from  bad  to  worse.  There  are  alternations  of  improvement 
and  relapse  ;  sometimes  the  looseness  is  better  for  a  day  or 
two,  and  may  even  seem  to  have  subsided ;  a  relapse  then 
takes  place,  and  the  condition  of  the  child  is  as  bad  as 
before.  These  variations  in  the  intensity  of  the  diarrhoea 
will  often  be  found,  in  the  earlier  periods  of  the  disease,  to 
coincide  with  variations  in  the  temperature  and  degree  of 
moisture  of  the  air.  A  damp,  chilly  day  is  usually  accom- 
panied by  increased  severity  of  the  symptoms,  while  on  a 
bright,  clear,  warm  day  the  disease  is  better. 

The  patient  begins  early  to  waste ;  but  unless  the  evacua- 
tions are  very  copious,  the  emaciation  does  not  proceed 
very  rapidly.  He  gets  pale,  and,  after  a  time,  of  a  peculiar 
earthy  tint,  which  is  very  characteristic.  The  skin  is  dry 
and  harsh,  the  eyes  are  hollow,  the  lips  pale  and  thin,  and 
the  fontanelle  is  depressed.  His  strength  diminishes,  and 
as  the  disease  advances  he  seems  to  lose  all  power  of  sup- 
porting himself,  and  lies  like  a  log  in  his  cot,  or  on  his 
nurse's  lap.  Still,  the  appetite  is  usually  preserved,  and 
he  will  often  take  food  eagerly  whenever  it  is  offered ;  but 
each  meal  is  followed  by  a  notable  increase  in  the  diarrhoea. 
His  food,  as  the  nurses  say,  seems  to  j)ass  through  him 
directly  it  is  swallowed."  The  tongue  is  moist,  often  quite 


SYMPTOMS 


69 


natural,  although  sometimes  the  papillse  at  the  edges  and 
tip  appear  unusually  red  and  prominent.  The  belly  may 
be  quite  flaccid  and  soft,  but  often  becomes  swollen  and 
tense  from  gas  generated  by  the  fermenting  food.  At 
these  times  there  is  some  pain,  shown  by  plaintive  cries, 
by  uneasy  movements  of  the  legs,  and  by  elevation  of  the 
corners  of  the  mouth.  The  abdominal  wall  is  never  re- 
tracted, and  there  is  seldom  any  tenderness  on  pressure. 

If  the  diarrhoea  continues,  the  wasting  becomes  more 
and  more  marked ;  the  bones  project ;  the  cheeks  get 
hollow ;  the  forehead  becomes  wrinkled ;  and  the  aspect 
generally  is  that  of  a  little,  infirm  old  man.  The  wrinkling 
of  the  forehead  is  due  to  loss  of  elasticity  of  the  skin, 
which  retains  the  folds  into  which  it  is  drawn.  The 
buttocks  and  inner  part  of  the  thighs  become  red  from 
eczema  occasioned  by  the  irritation  of  the  urine  and  fsecal 
discharges.  The  appetite  at  this  stage  may  be  preserved 
or  even  increased ;  but  more  often  it  becomes  capricious, 
and  the  child,  refusing  milk  and  sop,  craves  for  the  more 
tasty  articles  of  diet  which  he  sees  eaten  around  him. 
Sometimes,  however,  he  refuses  lo  take  any  nourishment 
whatever.  All  this  time  there  is  no  fever.  Indeed,  the 
temperature  is  lower  than  is  natural,  being  often  no  more 
than  97*5°  in  the  rectum. 

The  stools  are  now  excessively  frequent,  ten,  fifteen, 
twenty,  or  even  more,  in  the  four-and- twenty  hours. 
There  is  often  very  great  straining  with  each  evacuation, 
and  the  bowel  may  even  prolapse.  The  motions  often 
look  like  chopped  spinach  in  a  dirty-brown,  stinking 
water,  and  may  contain  blood — not  in  bright  red  streaks, 
as  at  the  first,  but  of  a  dirty,  brownish-yellow  colour,  and 
mixed  with  mucus  and  pus.  When  this  occurs  and  there 
is  at  the  same  time  tenderness  of  the  belly  on  pressure 
with  gurgling,  the  bowel  is  probably  ulcerated. 

There  are  certain  complications  liable  to  occur  in  this 
disease  which  often  hasten  the  end. 


70 


CHRONIC  DIARRHCEA 


Serous  effusions  may  take  place  on  account  of  the 
poverty  of  the  blood,  and  the  relaxed  attenuated  state  of 
the  coats  of  the  vessels.  They  begin  usually  at  the  feet, 
which  hang  down  as  the  child  lies  in  his  nurse's  lap.  The 
instep  gets  quite  round,  and  feels  doughy ;  the  skin  over 
it  is  thin,  and  looks  almost  transparent ;  the  contrast  thus 
presented  between  the  thin  wasted  leg  and  the  bulbous 
foot  is  very  striking  and  peculiar.  The  backs  of  the 
hands  and  the  fingers  then  become  swollen,  and  occa- 
sionally the  face  and  eyelids  are  also  oedematous.  Effusions 
may  also  take  place  into  the  serous  cavities,  the  pleura, 
peritoneum,  and  pericardium. 

Hypostatic  congestion  of  the  lungs  is  very  liable  to  occur, 
for,  as  the  child  lies  constantly  upon  his  back,  stasis  of  the 
blood  takes  place  in  the  most  depending  parts  of  his  lungs. 
Death  is  not  at  all  uncommon  from  this  cause.  Pneumonia 
is  an  occasional  complication.  It  gives  rise  to  fever,  but  in 
a  feeble,  wasted  subject  may  set  up  no  cough,  or  any  of  the 
other  symptoms  by  which  its  presence  is  usually  mani- 
fested. Probably  the  lung  complication  is  often  the  result 
of  microbic  infection. 

The  exanthemata  are  very  apt  to  attack  children  the 
subjects  of  this  disorder,  either  from  the  diminished 
resisting  power  of  the  system  induced  by  the  debility,  or 
from  such  a  condition  as  obtains  in  chronic  diarrhoea 
being  especially  favourable  to  the  reception  of  miasmatic 
poisons. 

Convulsions  may  carry  off  the  child  early  in  the  disease. 
They  are  not,  however,  commonly  seen  in  the  later  stages. 
Convulsions  are  very  common  in  children  in  whom  there 
is  a  sudden  depression  of  the  vital  powers,  and  are  there- 
fore frequently  seen  in  acute  diarrhoea,  where  there  is  a 
great  and  rapid  drain  upon  the  system.  In  these  cases, 
however,  where  the  debility  is  produced  more  gradually, 
although  a  greater  degree  of  prostration  may  be  reached, 
convulsions  are  rare,  for  the  child  then  assumes  some  of 


THROMBOSIS  OF  SINUSES 


71 


the  physiological  characters  of  old  age,  and  is  much  less 
liable  to  be  affected  by  reflex  stimuli. 

Thrombosis  of  the  cerebral  sinuses  may  be  a  cause  of 
death.  There  is  no  doubt  that  inspissation  of  the  blood 
resulting  from  the  watery  drain  from  the  bowels  must 
help  greatly  to  retard  the  circulation  through  the  cerebral 
sinuses.  The  speed  of  the  blood  current  is  further  reduced 
by  the  feeble  propulsive  power  of  the  weakened  heart. 
These  conditions  must  necessarily  favour  the  formation  of 
coagula  in  the  channels  of  the  brain,  and  where  there  is 
no  trace  of  inflammation  on  the  walls  of  the  sinuses  the 
plugging  may  be  due  to  this  agency  alone.  But  in  most 
cases  other  influences  are  at  work.  A  common  cause,  as 
Marfan  has  pointed  out,  is  infection.  According  to  this 
observer,  the  meningeal  hsemorrhages  and  thrombosis  of 
dural  sinuses,  which  are  so  apt  to  occur  in  the  terminal 
stage  of  gastro-intestinal  disorders  in  infancy,  are  due  to 
the  action  of  microbes  or  of  the  poison  they  generate. 
Micro-organisms  may  be  carried  into  the  blood  directly 
from  the  bowel ;  but  Simmoiids  lays  stress  upon  the 
influence  in  this  respect  of  otitis  media.  This  physician 
has  found  inflammation  of  the  middle  ear  to  be  common 
in  all  the  nutritive  disorders  of  early  life,  and  holds  that 
it  is  from  this  source  that  microbes  reach  the  circulation 
and  set  up  an  infective  phlebitis  in  the  sinuses.  It  is  to 
this  phlebitis  that  the  thrombi  are  commonly  due.  The 
child  falls  into  a  state  of  stupor,  with  dilated  pupils, 
occasional  strabismus,  retraction  of  the  head,  fulness  of 
one  or  both  jugular  veins,  and  sometimes  paralysis  of  the 
facial  nerve  on  one  side  of  the  face. 

Usually  it  is  the  longitudinal  sinus  which  is  blocked. 
On  dissection  it  is  found  to  be  filled  with  a  laminated, 
partially  decolourised  clot  which  adheres  more  or  less 
firmly  to  its  walls.  The  veins  opening  into  the  obstructed 
sinus  are  distended  with  blood. 

When  the  disease  terminates  fatally  the  child  often  dies 


72 


CHRONIC  DIARRHCEA 


from  one  of  the  above  causes.  Sometimes,  however,  he 
sinks  and  dies  without  our  being  able  to  say  that  any  of 
these  complications  are  present.  In  these  cases  the 
emaciation  becomes  extreme.  The  eyes,  deeply  sunken  in 
their  sockets,  have  a  dull,  ghastly  look ;  the  cheek-bones 
project ;  the  cheeks  sink  in ;  the  nose  looks  sharpened  ;  a 
furrow  passes  on  each  side  from  the  upper  part  of  the  ala 
of  the  nose,  and  forms  a  rough  semicircle  round  the  corners 
of  the  mouth ;  the  lips  are  red,  cracked,  and  covered  with 
sordes  ;  and  the  inside  of  the  cheeks  and  lips,  and  the 
surface  of  the  tongue,  become  aphthous,  or  are  coated 
with  thrush.  The  tongue  becomes  dry,  and,  when  free 
from  thrush,  is  apt  to  have  a  granular  appearance  from 
projecting  papillae.  The  complexion  is  dull  and  earthy- 
looking,  and  the  skin  seems  tightened  over  the  projecting 
bones  of  the  face.  The  fontanelle  is  deeply  depressed. 
The  body  generally  appears  to  consist  of  little  more  than 
the  bones  covered  by  the  dry,  rough,  flaccid  skin;  each 
rib  stands  out  sharp  and  distinct  on  the  wasted  chest. 
The  belly  may  be  flaccid,  but  more  usually  is  full  and 
prominent,  as  the  emaciated  and  relaxed  walls  yield  before 
the  pressure  of  the  flatus  in  the  bowels.  The  skin  of  the 
'  abdomen  becomes  of  a  dirty  brown  colour,  or  is  speckled 
with  brownish  spots.  The  feet  and  hands  are  cold,  and 
often  look  purple  even  when  not  actually  cold  to  the  touch. 
The  child  lies  quiet,  with  eyes  half  closed  and  dim.  Occa- 
sionally he  draws  up  the  corners  of  his  lips,  and  wrinkles 
his  brow  as  if  to  cry,  but  makes  no  sound  ;  but  for  this 
plaintive  sign,  and  for  his  slow,  quiet  breathing,  he  might 
be  thought  to  be  dead.  In  these  cases  death  takes  place 
almost  without  a  struggle,  and  it  is  often  difficult  to  say 
at  what  precise  moment  the  child  ceases  to  exist. 

Sometimes  for  a  few  days  before  death  the  evacuations 
entirely  cease,  but  no  false  hopes  should  be  raised  by  this 
change  if  a  corresj^onding  amendment  does  not  take  place 
in  the  general  symptoms. 


PROGRESS  OF  DENTITION 


73 


In  cases  of  recovery  the  stools  gradually  become  more 
homogeneous,  more  solid,  and  more  faecal,  and  one  great 
sign  of  improvement  is  the  reappearance  of  bile  in  the 
stools.  The  child  at  the  same  time  becomes  less  torpid ; 
his  eyes  get  brighter;  he  grows  intensely  fretful,  and 
manifests  his  uneasiness  by  crying.  The  reappearance  of 
tears  is  a  very  favourable  symptom,  and  one  which  allows  us 
to  entertain  strong  expectations  of  his  ultimate  recovery. 
He  ceases  to  emaciate,  and  soon  begins  to  regain  flesh — very 
slowly  at  the  first,  and  the  earliest  advance  in  this*  respect 
is  seen  about  the  buttocks,  which  will  be  noticed  to  have 
become  a  little  fuller  and  more  rounded.  The  stools 
gradually  lose  their  foetid  character,  get  more  healthy - 
looking,  and  constipation  usually  replaces  the  previous 
purging. 

Although  the  nutrition  of  the  body  is  so  much  interfered 
with  in  this  disease,  and  the  child  daily  emaciates  more  a,nd 
more,  yet  if  the  patient  be  not  the  subject  of  rickets,  the 
growth  and  development  of  the  teeth  may  continue  in 
spite  of  the  general  condition.  In  the  case  of  infants  who 
are  cutting  the  incisors,  these  teeth  usually  appear  without 
difficulty  or  apparent  aggravation  of  the  other  symptoms. 
Nor  does  the  eruption  of  each  tooth  appear  to  be  accom- 
panied by  any  special  improvement  which  can  be  attri- 
buted to  that  as  its  cause.  Dentition  goes  on  rapidly  and 
easily,  while  the  diarrhoea  remains  stationary,  or  slowly 
improves.  These  cases  generally  recover.  In  an  infant 
of  eight  months  old  whom  the  author  attended  for  this 
complaint,  five  incisor  teeth  made  their  appearance  in  the 
course  of  a  month.    The  child  got  well. 

If  the  patient  has  arrived  at  a  later  period  of  infancy, 
the  cutting  of  the  canines  and  back  molars  often  produces 
a  distinctly  injurious  effect  upon  the  intestinal  derange- 
ment. Indeed,  cases  are  sometimes  met  with  which 
obstinately  resist  all  treatment  until  the  teething  process 
has  come  to  an  end.    Still,  although  the  presence  of  an 


74 


CHRONIC  DIARRHCEA 


infiamed  and  swollen  gum  may  appear  to  increase  the 
irritation  of  the  bowel,  chronic  diarrhoea  is  not  necessarily 
associated  with  dentition  as  its  cause.  As  Dr.  John 
Cheyne  long  ago  pointed  out,  the  disease  is  often  seen 
in  cases  where  there  is  no  swelling  or  inflammation  of  the 
gums,  no  salivation  nor  any  appearance  of  pain  or  tender- 
ness about  the  mouth,  in  cases  where  the  child  is  cutting 
his  teeth  easily,  and  even  in  children  of  three  months  old, 
who  have  no  teeth  at  all.  We  shall  see  that  it  may  begin 
almost  at  birth. 

The  preceding  descrij^tion  applies  only  to  infants  and 
children  under  two  years  of  age.  In  older  children 
chronic  diarrhoea,  although  often  an  obstinate  disease,  is 
seldom  a  fatal  one.  The  nutrition  of  the  child  is  visibly 
affected,  and  he  becomes  pale,  and  thin,  and  delicate- 
looking.  He  is  noticed  to  be  easily  fatigued,  dislikes  his 
accustomed  walks,  and  often  lies  down  during  his  play. 
At  the  same  time  the  special  consequences  of  irritable 
bowels  are  generally  to  be  observed,  and  in  bad  cases 
night  terrors,  nocturnal  incontinence  of  urine,  unusual 
fretfulness  and  causeless  crying,  are  sources  of  great 
anxiety  to  the  parents,  who  attribute  them  at  once  to 
''irritation  of  the  brain."  The  child's  appetite  does  not 
necessarily  suffer;  indeed,  in  some  cases,  it  becomes 
unusually  keen,  so  that  the  presence  of  parasitic  worms  is 
suspected.  Often,  however,  it  is  capricious,  and  in  rare 
cases  may  be  lost  altogether. 

The  diarrhoea  is  subject  to  very  great  alternations.  It 
is  at  times  severe,  so  that  the  number  of  the  evacuations 
rises  to  ten  or  twelve  in  the  twenty-four  hours.  At  other 
times  for  several  days  together  it  seems  to  be  almost  well, 
but  the  motions  generally  remain  loose  and  slimy,  although 
their  number  is  reduced.  At  the  best  the  stools  consist 
of  offensive  pasty  matter  mixed  with  green  or  colourless 
mucus.  When  the  bowels  are  much  relaxed  the  discharge 
is  darker,  more  watery,  and  often  contains  small  lumps  of 


ARREST  OF  GROWTH 


75 


lighter-coloured  fsecal  matter.  These  variations  in  the 
intensity  of  the  diarrhoea  will  almost  invariably  be  found 
to  follow  changes  in  the  weather.  A  damp  cold  day 
increases  the  severity  of  the  complaint,  while  dryer  and 
warmer  weather  is  followed  by  temporary  improvement. 
In  children  past  the  age  of  infancy,  and  especially  in  those 
who  have  reached  the  age  of  six  or  seven  years,  chronic 
diarrhoea  with  proper  care  may  be  expected  to  get  well. 
Still  after  recovery  the  children  are  left  anaemic  and  weak 
and  subject  to  relapse.  Moreover,  there  is  another  curious 
consequence  of  the  disorder,  if  it  have  lasted  for  a  long 
time,  which  may  be  referred  to.  This  is  an  arrest  of 
growth.  Three  cases  of  the  kind  have  come  under  my 
notice  during  the  last  few  years.  In  each  of  these  the 
patient  had  suffered  from  repeated  attacks  of  long  con- 
tinued looseness  of  the  bowels  which  could  be  arrested  by 
treatment,  but  tended  to  break  out  again  and  again  after 
the  smallest  indiscretion.  One  of  these,  a  little  boy  at  the 
age  of  seven  years  and  nine  months,  was  3  feet  6^  inches 
in  height.  A  second,  a  girl  of  eight  and  a  half,  measured 
3  feet  6|  inches.  A  third,  also  a  little  girl,  at  ten  years 
old,  weighed  only  26  lbs.  9^  oz.,  and  measured  3  feet  3f 
inches  in  height.  All  these  children  are  growing  but  very 
slowly.  One  of  them  in  twelve  months  grew  only  seven- 
eighths  of  an  inch. 

A  form  of  diarrhoea  is  not  uncommon,  the  peculiarity  of 
which  consists  in  the  fact  that  the  motions  contain  little 
faecal  matter,  but  are  composed  almost  entirely  of  undi- 
gested food  mixed  with  mucus,  so  as  to  present  a  slimy 
appearance.  These  motions  are  passed  very  shortly  after, 
or  even  during,  a  meal;  the  food  taken  appears  to  be 
forced  with  extraordinary  rapidity  along  the  digestive 
tract,  and  to  be  voided  in  almost  the  same  state  in  which 
it  was  swallowed.  The  condition  which  gives  rise  to  this 
looseness  of  the  bowels  is  no  doubt  an  unnatural  briskness 
of  peristaltic  action.    The  intestines  are  in  a  state  of 


76 


CHRONIC  DIARRHCEA 


great  irritability,  so  that  food  taken  into  the  stomach  is  at 
once  conducted  along  the  ahmentarj  canal  with  a  rapidity 
which  allows  little  digestion  to  take  place  during  its 
passage. 

The  bowels  act  three,  four,  or  more  times  within  twenty- 
four  hours.  There  is  almost  always  an  evacuation  in  the 
morning  on  first  rising  from  bed,  and  afterwards  in  the 
course  of  the  day  each  meal  is  at  once  followed  by  a  like 
movement  of  the  bowels,  the  child  having  often  to  leave 
the  table  hurriedly,  and  frequently  before  the  repast  is 
actually  concluded.  Each  motion  is  preceded  by  griping 
pains  in  the  belly,  and  is  characterised  by  excessive 
urgency,  the  patient  having  great  difficulty  to  restrain  his 
desire  during  the  time  necessary  to  enable  him  to  reach 
the  closet.  These  griping  pains  are  not  always  followed 
by  a  stool,  but  may  come  on  and  go  off  at  irregular  times 
in  the  course  of  the  day  without  any  result.  Sometimes, 
however,  they  are  accompanied  by  a  desire  to  go  to  stool, 
although  no  motion  is  actually  passed.  The  tongue  may 
be  a  little  furred,  but  is  usually  clean,  and  is  often  red  at 
the  tip  and  sides,  the  redness  being  due  to  small  crimson 
papillae,  which  are  sometimes  slightly  elevated. 

This  variety  of  diarrhoea  is  found  in  children  of  from 
three  or  four  to  nine  or  ten  years  of  age.  It  often  causes 
marked  wasting,  and  the  evident  ill-health  of  the  child 
excites  great  anxiety  amongst  his  friends.  Still,  in  many 
cases,  special  inquiry  has  to  be  made  into  the  condition  of 
the  bowels,  for  as  the  evacuations  are  not  numerous,  the 
state  of  the  digestive  organs  excites  little  attention,  and 
the  existence  of  looseness  is  often  not  even  hinted  at  by 
the  mother  in  her  account  of  her  child's  illness. 

Causes. — Chronic  diarrhoea  may  usually  be  traced  to 
three  different  sets  of  causes,  viz.  unwholesome  surround- 
ings, impressions  of  cold,  and  the  occurrence  of  some 
previous  acute  disease. 

The  disorder  is  very  apt  to  attack  children  who  are 


CAUSES 


77 


exposed  to  insanitary  conditions,  and  the  younger  the 
infant  at  the  time  when  these  injurious  influences  are  at 
work  the  more  liable  is  he  to  suffer  from  their  effects  in 
this  particular  way. 

Improper  food  has  already  been  strongly  insisted  on  as 
a  cause  of  defective  nutrition  in  the  child,  and  by  the 
weakness  which  it  invariably  induces  would  alone  render 
him  less  able  to  resist  any  other  pernicious  agencies  to 
which  he  might  be  exposed.  But,  in  addition,  the  con- 
tinued passage  along  the  bowels  of  masses  of  indigestible 
food  must  cause  constantly  renewed  irritation  to  his  deli- 
cate mucous  membrane,  and,  if  the  same  diet  be  persisted 
in,  must  lead  in  time  to  diarrhoea.  When  due  to  this 
cause,  there  are  three  periods  at  which  the  disease  is  most 
usually  found  to  manifest  itself. 

If  the  child  be  brought  up  by  hand,  he  may  be  subject 
to  it  from  his  very  birth.  In  these  cases  the  infant  not 
only  does  not  grow,  but,  as  his  fat  gradually  disappears, 
he  seems  even  to  become  smaller  and  more  puny.  It  is 
not  uncommon  for  a  mother  to  say,  speaking  of  a  child  of 
two  or  three  months  old,  who  all  his  short  life  has  been 
suffering  from  this  complaint,  "  No  food  seems  to  do  him 
any  good ;  he  is  smaller  than  when  he  was  born." 

If  the  mother  is  able  to  nurse  her  child,  he  often  goes 
on  well  for  four  or  five  months,  but  then  being  supplied 
with  other  and  less  digestible  food,  as  an  addition  to  the 
breast  milk — food  which  is  often  ill- selected,  and  consists 
not  unfrequently,  of  portions  of  the  meals  of  his  parents — 
he  begins  to  waste,  and  the  diarrhoea  is  set  up. 

The  third  period  at  which  this  disorder  is  apt  to  show 
itself  is  the  time  of  weaning.  It  is  at  this  time  that  the 
simple  food  on  which  he  has  hitherto  principally  sub- 
sisted being  withdrawn,  he  is  so  exposed  to  danger  from 
the  mistaken  kindness  of  his  attendants,  who,  confusing 
substantial  with  nutritious  food,  supply  him  with  articles 
of  diet  which  they  consider  suitable  to  Ms  needs,  because 


78 


CHRONIC  DIARRHCEA 


they  know  them  to  be  sufficient  for  their  own.  The 
length  of  time  during  which  children  amongst  the  poorer 
classes  are  suckled  in  this  country  also  favours  the  result 
described.  The  infant  is  often  kept  at  the  breast  long 
after  there  is  any  nourishment  to  be  obtained  from  his 
mother's  milk.  The  degree  of  weakness  to  which  he  is 
reduced  by  such  a  system  enfeebles  his  digestive  power, 
and  prevents  him  even  from  assimilating  such  a  diet  as, 
were  he  in  health,  would  afford  him  the  nourishment  he 
requires. 

Even  while  at  the  breast,  the  infant  is  not  exempt  from 
danger.  Hired  nurses,  in  whom  the  breast  milk  is  not 
sufficient  in  quantity  or  quality  for  the  child's  support, 
will  often  feed  him  secretly  with  farinaceous  or  other  food, 
in  order  that  the  deficiency  may  pass  undetected.  This  is 
not  an  uncommon  source  of  disease  in  very  young  infants. 
In  these  cases  it  is  difficult  to  extort  a  confession  from  the 
nurse,  but  our  suspicions  are  often  verified  by  a  micro- 
scopic examination  of  the  stools,  when  starch  granules  will 
be  found  in  large  numbers. 

Bad  air,  want  of  sunlight,  and  want  of  cleanliness,  are 
also  fruitful  sources  of  this  disease,  especially  when,  as  is 
usually  the  case,  they  are  combined  with  the  preceding. 
The  crowding  together  of  children  in  rooms,  where  they 
live  and  sleep  in  a  close  atmosphere,  is  a  frequent  cause 
of  derangements  of  the  stomach  and  bowel.  In  an  insti- 
tution with  which  the  writer  was  for  many  years  connected, 
founded  for  the  temporary  reception  of  single  women  with 
their  offspring,  it  was  noticed  that  when  the  occupants  of 
the  infants'  sleeping  nursery  reached  a  certain  number,  one 
or  two  deaths  were  certain  to  occur  from  bowel  complaints, 
and  this  in  spite  of  all  possible  precautions  in  the  way  of 
ventilation,  &c.  It  was  only  by  making  arrangements  for 
distributing  the  number  amongst  several  rooms  that  this 
mortality  could  be  avoided. 

Chilling  of  the  surface  is  another  common  cause  of 


EFFECT  OF  CHILL 


79 


diarrhoea.  Owing  to  extreme  sensitiveness  to  changes  of 
temperature  in  early  life,  children  are  very  subject  to 
catarrhs  of  their  mucous  membranes,  and  it  often  happens 
that  it  is  not  the  mucous  membrane  of  the  throat  or  lungs 
which  suffers,  but  that  of  the  stomach  and  bowels.  An 
intestinal  catarrh  once  set  up,  predisposes  to  a  second 
attack.  In  this  way,  by  a  succession  of  slight  chills,  a 
child  may  pass  from  one  attack  of  intestinal  catarrh  to 
another,  and  may  eventually  die  from  a  derangement  which 
a  little  care  and  suitable  treatment  at  the  beginning  would 
have  arrested  without  difficulty. 

Infants  who  are  "  short-coated  "  in  cold,  damp  weather, 
often  owe  the  beginning  of  an  obstinate  diarrhoea  to  the 
same  cause.  This  change,  so  dear  to  the  heart  of  a  mother, 
is  often  made  recklessly,  and  without  any  care  to  suj^ply 
the  place  of  the  clothing  which  is  withdrawn.  It  is  not, 
therefore,  wonderful  that  the  child  should  suffer  from  the 
unaccustomed  exposure ;  for,  if  an  infant,  at  an  age  when 
warmth  is  a  pressing  necessity,  be  suddenly  deprived  of 
the  chief  protection  to  its  lower  limbs  and  belly,  the  con- 
sequences may  be  expected  to  be  serious. 

Older  children  also  are  often  very  sensitive  to  changes 
of  temperature,  and  chilling  of  the  surface  is  in  them, 
too,  a  frequent  cause  of  persistent  looseness  of  the 
bowels. 

The  infectious  fevers,  esjDecially  measles  and  whooping- 
cough,  no  doubt  often  prepare  the  way  for  this  disorder, 
as  do  pneumonia  and  most  catarrhal  complaints ;  but  in 
these  cases,  too,  the  exciting  cause  is  probably  a  chill 
acting  upon  a  system  made  exceptionally  susceptible  by  the 
late  illness. 

In  some  children  the  presence  of  the  ascaris  lumbricoides 
in  the  alimentary  canal  will  give  rise  to  diarrhoea  which 
may  continue  for  months,  now  better,  now  worse,  and 
only  be  finally  arrested  by  the  expulsion  of  the  worm.  In 
these  cases  the  diarrhoea  is  most  troublesome  at  night,  the 


80 


CHRONIC  DIARRHOEA 


bowel  during  the  day  being  much  less  disturbed,  and  is 
accompanied  by  great  straining,  and  often  by  prolapsus 
ani. 

When  arising  from  the  causes  which  have  been  men- 
tioned, chronic  diarrhoea  is  the  result  merely  of  a  functional 
disorder  of  the  bowels.  It  is  a  derangement  rather  than 
a  disease,  but  may  become  serious  if  not  promptly  taken  in 
hand ;  indeed,  in  young  and  weakly  subjects  it  often  proves 
fatal.  There  is,  however,  another  form  of  the  diarrhoea 
found  in  older  children,  which  is  of  constitutional  origin. 
Young  persons,  like  their  elders,  who  are  the  subjects  of 
pulmonary  disease,  are  apt  to  suffer  from  secondary  ulcera- 
tions of  the  bowel,  and  the  chronic  diarrhoea  which  is  thus 
excited  hastens  the  fatal  termination  of  the  illness.  This 
variety  of  chronic  diarrhoea  is  rare  in  infants :  it  is  most 
commonly  found  after  the  age  of  three  years. 

Morbid  Anatomy. — The  morbid  appearances  found  after 
death  are  very  variable.  On  opening  the  bowel  there  may 
be  no  obvious  change  to  strike  the  eye,  but,  as  a  rule,  we 
find  the  mucous  membrane  tinted  of  a  dull  grey  colour,  and 
on  it  we  may  notice  a  number  of  minute  dark  grey  points 
giving  the  so-called  "  cut-beard appearance  from  pigmen- 
tation round  the  opening  of  the  little  follicles.  Examina- 
tion with  the  microscope  shows  minute  changes.  Many  of 
the  small  tubular  glands  have  disappeared,  and  there  is 
considerable  cell  proliferation  in  the  adenoid  tissue  of  the 
mucosa.  With  this  there  is  formation  of  new  connective 
tissue  in  cases  of  long  standing.  In  the  small  intestine 
there  may  be  some  loss  of  villi.  These  changes  are  not 
uniformly  distributed  over  the  mucous  membrane,  but 
occur  here  and  there  irregularly. 

If  there  has  been  a  recent  acute  exacerbation,  we  often 
find  a  patchy  inflammation  of  the  mucous  membranes  which 
may  be  limited  to  the  tops  of  the  longitudinal  folds. 
Ulceration  is  rare  except  in  protracted  cases. 

The  ulcers  are  shallow,  and  are  often  difficult  to  detect 


MORBID  ANATOMY 


81 


except  by  looking  sideways  at  the  surface,  for  their  bases 
are  of  the  same  colour  as  the  parts  around  them.  They 
may  occupy  either  the  summits  of  the  longitudinal  folds — 
when  they  are  elongated  and  sinuous,  or  may  be  situated 
between  the  folds — when  they  are  very  small  and  circular. 
Mixed  up  with  the  ulcers  we  see  solitary  glands  and 
follicles  enlarged  and  elevated  above  the  surface,  looking 
like  little  transparent  pearls.  The  base  is  often  sur- 
rounded by  a  ring  of  congested  vessels.  This  state  of  the 
follicle  is  the  first  step  in  the  process  of  ulceration.  After 
a  time  suppuration  takes  place,  so  that  the  contents  of  the 
follicle  become  purulent,  and  the  follicle  itself  still  further 
increases  in  size.  Lastly,  the  purulent  matter  escapes  ;  the 
roof  dies,  and,  becoming  detached  at  the  edges,  leaves  a 
sharply- circumscribed  roundish  ulcer.  The  pearly  appear- 
ance of  enlarged  follicles  is  often  seen  during  life  on  the 
inside  of  the  mouth  dotting  the  mucous  membrane  of  the 
cheek. 

The  mucous  membrane,  when  much  inflamed,  is  often 
exceedingly  soft,  and  may  be  much  thickened ;  but  in  long- 
standing cases  where  there  is  great  emaciation,  the  lining 
membrane  becomes  thin,  and  in  some  cases  hardly  seems 
to  exist  at  all. 

These  changes  are  sometimes  found  to  extend  into  the 
small  intestine,  which  may  be  inflamed  or  ulcerated  for  a 
short  distance  above  the  ilio-csecal  valve ;  but  in  the  large 
majority  of  cases  the  lesions  are  limited  to  the  colon. 

The  mesenteric  glands  are  sometimes  swollen  from 
excessive  cell  proliferation. 

The  simple  or  catarrhal  form  of  ulceration  described 
above  may  be  seen  in  young  babies  of  any  age ;  but  there 
is  another  variety  which  is  met  with  in  children  of  three 
or  four  years  of  age  and  upwards.  Tuberculous  ulceration 
of  the  bowels  is  common  as  a  consequence  of  pulmonary 
and  abdominal  tuberculosis.  The  ulcers  are  usually  found 
in  the  ilium,  and  occupy  Peyer's  patches  and  the  solitary 

6 


82 


CHRONIC  DIAKRHCEA 


follicles — particularly  those  in  tlie  neighbourhood  of  the 
ilio-csecal  valve.  As  the  ulcers  extend  they  pass  beyond 
the  boundaries  of  the  patch  and,  meeting  other  ulcers, 
coalesce  with  them  so  as  to  form  circular  or  oval  breaches 
of  surface.  The  latter  lie  transversely  across  the  bowel. 
Tuberculous  sores  rarely  rupture  on  account  of  the  thick- 
ening of  the  tissues  at  the  base  and  the  adhesions  which 
are  formed  with  underlying  parts. 

This  form  of  ulceration  is  invariably  joined  with  tuber- 
culous disease  of  the  mesenteric  glands,  and  is  often  only 
a  part  of  a  general  distribution  of  tubercle  throughout  the 
body. 

Diagnosis. — If  the  child  is  seen  early  before  the  estab- 
lishment of  actual  diarrhoea,  the  nature  of  the  derange- 
ment can  be  readily  inferred  from  the  course  and  nature 
of  the  symptoms  and  the  character  of  the  stools.  In  most 
cases,  unless  questioned  closely  upon  the  matter,  the 
mother  will  not  mention  the  state  of  the  bowels,  or  will 
merely  say  that  they  are  regularly  relieved.  Sometimes 
the  enormous  quantity  of  the  alvine  discharge  attracts  her 
notice ;  but  it  is  rare  for  information  with  regard  to  the 
state  of  the  stools  to  be  obtained  without  direct  inquiry. 
In  all  cases,  therefore,  where  a  child,  whatever  its  age,  is 
becoming  pale  and  thin,  and  is  found  to  be  losing  strength, 
the  condition  of  the  bowels  and  the  state  of  the  dejections 
should  receive  careful  attention.  At  this  period  of  the 
derangement  gradual  loss  of  flesh,  colour,  and  strength 
may  be  the  only  symptoms  complained  of.  The  appetite 
is  often  good  and  the  spirits  of  the  child  may  seem  little 
affected.  Sometimes,  indeed,  the  appetite  is  unusually 
keen,  and  the  mother  will  declare  that  she  cannot  think 
what  is  the  matter  with  the  child,  for  in  spite  of  all  the 
food  he  takes  he  gets  paler  and  thinner. 

Tuberculosis  is  often  suspected  in  these  cases,  and, 
indeed,  the  general  appearance  of  the  child  and  the  vague- 
ness of  the  symptoms  are  calculated  at  first  to  convey  a 


DIAGNOSIS 


83 


false  impression  as  to  the  nature  of  the  complaint.  Still, 
the  absence  of  pyrexia  is  a  valuable  negative  symptom  in 
excluding  tubercle ;  and  the  character  of  the  stools  amply 
accounts  for  the  faulty  nutrition  of  the  patient. 

If  the  case  be  first  seen  after  diarrhoea  has  become 
established,  it  is  important  to  exclude,  if  possible,  the 
presence  of  tuberculous  ulceration  of  the  bowels.  To  do 
so  we  must  consider  the  age  of  the  child,  the  circum- 
stances under  which  the  purging  commenced,  and  the 
existence  of  disease  in  other  organs. 

If  the  derangement  date  from  a  few  days  after  birth,  or 
from  the  time  of  weaning,  or  if  the  patient  be  an  infant 
who  has  been  injudiciously  fed,  insufficiently  clothed,  or 
neglected  and  exposed  to  privation,  the  case  is  in  all 
probability  one  of  simple  intestinal  catarrh.  Moreover, 
the  age  of  the  child  furnishes  in  itself  a  strong  presump- 
tion in  favour  of  this  view,  for  during  the  first  year,  or 
even  the  first  two  years  of  life,  chronic  diarrhoea  is  almost 
invariably  catarrhal.  In  any  case,  after  an  examination 
of  the  whole  body,  we  should  not  neglect  to  take  the 
child's  temperature  by  introducing  the  bulb  of  the  ther- 
mometer into  the  rectum.  In  simple  chronic  diarrhoea 
the  temperature  is,  if  anything,  lower  than  in  health,  and 
does  not  become  elevated  in  the  evening.  If,  then,  we  find 
that  the  heat  of  the  body  is  not  increased,  we  have  just 
grounds  for  believing  the  case  to  be  an  ordinary  one  of 
chronic  functional  derangement.  We  must,  however,  be 
on  our  guard  against  drawing  wrong  inferences  from  the 
presence  of  fever.  Teething,  or  other  sources  of  irritation, 
may  cause  a  rise  in  the  temperature.  Therefore,  we 
should  in  all  cases  satisfy  ourselves  as  to  the  condition  of 
the  gums,  remembering  that  children  sometimes  cut  their 
teeth  at  four  months  old,  and  that  chronic  diarrhoea  does 
not  delay  dentition.  The  temperature  of  a  teething  child 
is  often  as  high  in  the  morning  as  at  night,  and  varies 
from  time  to  time  capriciously.    If  diarrhoea  is  present, 


84 


CHRONIC  DIAKRHCEA 


howev(;r,  the  pyrexia  rarely  lasts  longer  than  twenty-four 
hours. 

Older  children  suffer  also  from  chronic  intestinal  catarrh ; 
but  in  them,  as  there  is  stronger  probability  that  the 
disease  may  be  due  to  ulceration  of  a  tuberculous  nature, 
the  other  organs  should  be  examined  with  peculiar  care 
for  signs  of  disease.  The  chest  should  be  searched  for 
evidence  of  pulmonary  mischief,  and  the  abdomen  for 
enlarged  mesenteric  glands  and  signs  of  peritonitis.  Ten- 
derness on  pressure  of  the  belly  in  the  right  iliac  fossa, 
with  a  certain  amount  of  tension  of  the  parietes  in  that 
situation,  would  lead  us  to  suspect  the  existence  of  ulcera- 
tion. The  kind  of  stool  most  characteristic  of  this  con- 
dition is  that  composed  of  dirty-brown  fluid,  with  a 
deposit  containing  flaky  matter,  and  small  black  clots  of 
blood,  with  mucus  and  pus,  the  whole  being  intensely 
offensive. 

When  the  child,  after  cessation  of  the  diarrhoea  and  the 
beginning  of  convalescence,  suddenly  ceases  to  improve, 
the  presence  of  some  complication  should  be  suspected. 
If  the  temperature  becomes  febrile,  the  lungs  should  be 
examined  for  pneumonia,  and  the  ears  for  otitis  media. 

Prognosis. — The  prospects  of  the  patient  will  vary  ac- 
cording to  the  cause  of  the  diarrhoea,  the  age  of  the  child, 
and  the  intensity  and  obstinacy  of  the  purging. 

If  there  is  pulmonary  disease,  with  tuberculous  mesen- 
teric glands,  and  especially  if,  in  addition,  signs  of  ulcera- 
tion of  the  bowels  can  be  detected,  recovery  can  scarcely 
be  hoped  for. 

In  cases  of  simple  chronic  catarrh  the  prognosis  is 
more  serious  in  children  under  two  years  of  age  than  in 
older  children ;  but  even  in  an  infant,  chronic  diarrhoea  is 
not  difficult  of  cure  so  long  as  the  attacks  of  purging  are 
intermittent,  however  short  the  intermissions  may  be. 
When  the  looseness  of  the  bowels  becomes  a  confirmed 
derangement   the  chances  of   recovery  are  diminished. 


PROGNOSIS 


85 


Still,  even  in  these  cases,  if  the  infant  be  of  good  consti- 
tution, we  may  entertain  hopes  of  a  favourable  issue.  If 
there  be  hereditary  taint,  as  syphilis ;  if  the  child  be 
suffering  from  rickets  in  any  but  a  mild  form  ;  or  if  he  be 
much  reduced  in  strength  at  the  time  when  he  first  comes 
under  notice,  the  prognosis  is  serious. 

When  secondary  to  acute  disease,  the  case  is  graver 
than  when  the  derangement  is  primary  and  non-febrile 
from  the  first.  The  most  favourable  cases  are  those  which 
are  due  unmistakably  to  error  in  feeding,  or  to  neglect, 
provided  treatment  be  begun  before  symptoms  of  exhaus- 
tion have  set  in.  In  such  cases  we  may  hope  by  careful 
treatment  to  arrest  the  purging,  before  any  ulceration  has 
been  set  up  in  the  alimentary  canal. 

The  form  of  stool  which  is  of  worst  augury  is  that 
which  has  been  described  as  characteristic  of  ulceration  in 
the  bowels.  The  thicker  and  more  homogeneous  the  mo- 
tions become,  although  they  may  at  the  same  time  remain 
intensely  offensive,  the  more  favourable  is  the  prognosis. 

The  occurrence  of  any  complication  should  give  rise  to 
very  great  anxiety.  Measles  especially  is  apt  to  cause  a 
sudden  and  violent  increase  in  the  intensity  of  the  diar- 
rhoea ;  and,  moreover,  its  own  course  is  often  rendered 
irregular  by  the  presence  of  the  intestinal  disorder,  so  that 
retrocession  of  the  eruption  and  other  alarming  symptoms 
may  ensue.  The  prognosis  is  also  rendered  very  unfavour- 
able if  the  tongue  become  dry  and  rough,  if  thrush 
appear  upon  the  inside  of  the  mouth,  or  if  dropsy  occur. 

Amongst  the  favourable  signs  may  be  included — 
continuance  of  the  natural  process  of  dentition ;  the 
appearance  of  tears ;  and  the  occurrence  of  any  eruption  * 
(unconnected,  of  course,  with  any  of  the  exanthema) 
upon  the  child's  body,  even  although  the  diarrhoea  may 
not  at  the  time  have  undergone  any  visible  improvement. 

Prevention. — Diarrhoea  may  be  prevented  by  attention 
*  Underwood. 


86 


CHRONIC  DIARRHOEA 


to  the  diet  and  general  management  of  the  child.  All 
indigestible  food  is  calculated,  in  its  passage  through  the 
bowels,  to  give  rise  to  irritation,  and  therefore  to  cause  an 
increased  flow  of  watery  fluid  from  the  vessels  of  the 
intestines.  It  is  unnecessary  to  repeat  here  the  directions 
which  have  been  already  given  for  the  feeding  of  young 
children,  and  the  reader  is  referred  to  the  section  on  the 
treatment  of  simple  atrophy  for  full  information  upon  this 
subject.  It  may,  however,  be  remarked  that  the  practice 
of  giving  to  very  young  children  sweet  cakes  and  articles 
of  confectionery  between  their  regular  meals,  and  as 
rewards  for  good  behaviour,  is  one  to  be  very  strongly 
deprecated.  Sweet  cakes  are  especially  to  be  avoided,  as 
they  are  so  apt  to  undergo  fermentation  in  the  alimentary 
canal. 

As  cold  is  so  common  a  cause  of  diarrhoea  in  children 
great  care  should  be  taken  to  shield  them  from  this  source 
of  danger.  But  they  should  not,  therefore,  be  confined 
too  strictly  to  the  house.  Fresh  air  is  as  important  to 
them  as  simple  nourishing  food.  Healthy  infants  should 
be  taken  out  at  certain  periods  of  the  day  whenever  the 
weather  permits.  It  is  not  so  much  cold  as  daw/p  air 
which  is  dangerous  to  infants,  and  even  in  damp  air, 
unless  it  be  actually  raining,  a  short  expedition  is  not 
hurtful  to  a  robust  child,  provided  sufficient  precautions 
be  taken.  The  child  should  be  warmly  dressed,  should  be 
carried  briskly  along,  and  should  not  be  allowed  to  remain 
out  too  long  at  a  time.  If  there  is  any  wind  his  face 
should  be  protected  with  a  woollen  veil.  As  an  additional 
defence,  a  flannel  bandage  should  be  worn  round  the  body 
next  to  the  skin.  This  is  an  article  of  clothing  no  infant 
or  young  child  should  be  without.  It  should  be  looked 
upon  as  a  necessary  part  of  his  dress.  The  band  should 
be  sufficiently  wide  to  cover  the  whole  belly  from  the  hips 
to  the  waist,  and  long  enough  to  go  twice  round  the  body. 
It  should  be  secured  by  "  safety  "  pins ;  and  in  fitting  it 


AVOIDANCE  OF  CHILL 


87 


care  should  be  taken  to  wrap  the  bandage  tightly  round 
the  hips,  so  that  it  may  not  slip  up  and  leave  the  lower 
part  of  the  belly  exposed.  The  band  is  more  elastic  if  cut 
diagonally  from  the  piece  of  flannel. 

Sudden  changes  of  temperature  are  especially  to  be 
avoided,  and  a  rapid  change  from  cold  to  heat  appears  to 
be  as  prejudicial  as  a  similar  passage  from  heat  to  cold. 
It  is,  therefore,  necessary  to  prevent  an  infant  being  taken 
too  quickly  to  a  hot  fire  after  exposure  to  the  cold  of  the 
outside  air.  The  child  should  not  be  allowed  to  wait, 
clothed  in  his  out- door  dress,  in  a  warm  room,  before 
taking  his  airing.  He  should  be  taken  out  directly  he  is 
dressed  for  the  walk.  While  out,  he  should  be  kept  in 
movement,  and  should  not  be  allowed  to  remain  motion- 
less in  a  current  of  cold  air.  If  the  weather  is  cold,  damp, 
and  gloomy,  he  should  be  brought  back  to  the  house  after 
only  a  short  stay  in  the  open  air.  A  pinched  look  about 
the  face,  with  coldness  and  blueness  of  the  extremities,  are 
certain  signs  that  he  is  no  longer  receiving  benefit  from 
his  airing.  If  a  perambulator  be  used,  the  child,  on  cold 
days,  may  rest  his  feet  upon  a  hot  water-bottle. 

During  dentition  the  rules  here  laid  down  must  be 
especially  observed,  for  it  is  at  such  times,  when  the  teeth 
are  pressing  through  the  gum,  that  diarrhoea  is  so  com- 
mon. Many  children  are  said  always  to  cut  their  teeth 
with  diarrhoea.  Perhaps,  however,  dentition  in  these  cases 
is  not  so  entirely  to  blame  as  is  commonly  supposed.  No 
doubt,  during  the  cutting  of  the  teeth,  the  bowels  gene- 
rally are  in  a  state  of  irritability,  for  we  know  that  at 
these  periods  the  follicular  apparatus  of  the  intestines  is 
undergoing  considerable  development.  The  bowels  then 
are  ripe  for  diarrhoea ;  there  is  increased  sensitiveness  to 
the  ordinary  exciting  causes  of  purging ;  but  without  the 
presence  of  these  exciting  causes  diarrhoea  is  by  no  means 
a  necessary  result  of  such  a  condition  of  the  alimentary 
canal.    We  find  that  looseness  of  the  bowels  is  a  more 


88 


CHRONIC  DIARRHCEA 


common  accompaniment  of  dentition  in  summer  and 
autumn  than  in  winter ;  that  is,  at  a  season  when  the 
changes  of  temperature  are  rapid  and  unexpected,  and 
when  therefore  the  child  is  particularly  exposed  to  sudden 
chills  ;  rather  than  at  a  time  of  the  year  when  the  tem- 
perature, though  lower,  is  more  uniformly  low,  and  when 
precautions  are  more  naturally  taken  against  the  cold. 
Moreover,  when  the  early  teeth  appear  the  child  is  ceasing 
to  depend  for  nourishment  entirely  upon  his  mother's 
milk.  His  digestive  organs  are,  therefore,  apt  to  be 
deranged  by  articles  of  diet  unsuited  to  his  age.  Even  if 
the  diet  be  a  suitable  one  for  the  infant  when  in  health, 
it  by  no  means  follows  that  the  same  regimen  will  be 
found  equally  appropriate  at  a  time  when  the  febrile 
irritation  set  up  by  the  advancing  tooth  has  temporarily 
reduced  his  digestive  power.  His  ordinary  diet  may  then 
become  indigestible,  and  therefore  irritating  to  his  bowels. 

Treatment. — The  marked  influence  exercised  upon  chronic 
diarrhoea  in  children  by  variations  in  the  temperature  and 
degree  of  moisture  of  the  air  indicates  an  important  means 
of  checking  the  disease. 

The  infant  must  be  kept  as  nearly  as  possible  in  an 
equable  temperature  of  from  60°  to  65°  Fahr.  Free 
ventilation  must  be  sustained  by  an  open  fire,  or  in  warm 
weather  by  a  lamp  placed  in  the  fender ;  but  all  draughts 
of  air  should  be  carefully  guarded  against.  Where  prac- 
ticable, two  adjoining  rooms,  having  a  door  of  communi- 
cation between  them,  should  be  chosen.  The  child  may 
then  inhabit  them  alternately,  and  during  his  absence  the 
unoccupied  apartment  can  be  freely  ventilated.  Even 
where  this  convenience  is  unattainable,  two  rooms,  although 
separated  from  one  another  by  a  passage,  should  be  always 
made  use  of ;  the  child  can  be  taken  from  one  to  the  other 
without  danger  if  wrapped  from  head  to  foot  in  a  blanket. 
At  night,  air  should  be  admitted  into  the  room  as  freely 
as  is  consistent  with  the  avoidance  of  draughts ;  with 


TREATMENT 


89 


this  object,  the  door  of  the  room  may  be  left  open,  or  in 
dry  warm  weather  the  window  may  be  opened  for  a  short 
distance  at  the  top.  In  damp  weather,  however,  or  in 
seasons  when  the  temperature  falls  notably  at  sunset,  this 
must  be  prohibited.  If  possible,  the  infant  with  his  nurse 
should  be  the  only  occupants  of  the  bedroom,  and  no 
cooking  of  any  kind  should  be  allowed  in  the  nursery. 

If  a  flannel  bandage  have  not  been  previously  in  use,  it 
must  be  at  once  applied  as  directed  above.  This  precau- 
tion should  on  no  account  be  neglected.  Flannel,  which 
is  a  non-conductor,  forms  by  far  the  most  efficient  pro- 
tection to  the  belly  against  sudden  changes  of  tempera- 
ture. Chronic  diarrhoea  is,  no  doubt,  frequently  kept  up 
by  a  succession  of  chills,  just  as  a  coryza  or  pulmonary 
catarrh  may  be  prolonged  almost  indefinitely  by  the  same 
means.  By  the  use  of  this  safeguard  we  at  any  rate 
ensure  ourselves  from  having  to  deal  with  a  series  of 
catarrhs.  For  the  same  reason  the  feet  and  legs  should  be 
covered  with  woollen  stockings.  It  is  well  known  that 
cold  feet  have  a  very  bad  effect  on  an  irritable  stomach  and 
bowels,  and  in  children,  otherwise  healthy,  often  produce 
severe  pain  in  the  belly.  In  a  child  suffering  from  abdo- 
minal pains,  the  feet  should  always  be  examined,  and  if 
cold,  it  is  usually  found  that  on  warming  them  the  mani- 
festation of  pain  ceases. 

Great  cleanliness  must  be  observed.  All  soiled  napkins 
must  be  removed  from  the  room  at  once,  and  the  bedding 
should  be  taken  away  every  morning  and  exposed  freely 
to  the  air.  The  nates  should  be  carefully  sponged  and 
dried  after  each  motion,  and  should  then  be  dusted  over 
with  powdered  lycopodium  or,  if  the  skin  is  abraided,  with 
a  powder  composed  of  oxide  of  zinc  and  starch  in  equal 
proportions  made  antiseptic  with  a  sixth  part  of  boric  acid. 

With  regard  to  washing  of  the  child's  body,  the  utmost 
care  must  be  taken  not  to  expose  the  sensitive  patient  to 
cold.    An  ordinary  washing  bath  is  out  of  the  question  on 


90 


CHRONIC  DIARRHCEA 


account  of  the  lengthened  exposure  it  entails.  My  practice 
in  these  cases  is  to  order  the  child  to  be  sponged  for  one 
minute  by  the  clock  in  a  bath  of  hot  soap-suds.  Such  a 
washing,  if  done  quickly,  is  the  method  the  least  likely  to 
give  him  a  chill.  In  bad  cases  where  the  patient  is  wasted 
and  weak  with  a  feeble  circulation  and  cold  extremities  I 
forbid  washing  altogether,  except  local  sponging  after  a 
stool,  and  order  the  feet,  legs,  and  belly  to  be  swathed 
thickly  in  cotton  wool.  1  have  kept  children  so  wrapped 
up  for  six  weeks  or  two  months  at  a  stretch,  allowing 
mere  local  sponging  of  the  face,  hands,  and  nates ;  and 
believe  that  by  this  means  I  have  been  enabled  to  bring  to 
a  successful  issue  cases  which  otherwise  would  have  ended 
in  a  very  different  way. 

The  next  thing  is  carefully  to  regulate  the  diet.  If 
the  patient  be  an  infant  at  the  breast,  who,  besides  his 
mother's  milk,  has  been  overfed  with  farinaceous  food, 
or  allowed  to  swallow  unsuitable  morsels  from  his  parents' 
table,  a  strict  limitation  to  the  breast  will  often  produce 
a  surprisingly  beneficial  effect  upon  the  derangement.  If 
the  infant  has  been  fed  artificially  without  judgment,  the 
engagement  of  a  good  wet-nurse  will  often  have  a  simi- 
larly favourable  influence.  If,  however,  this  plan  of 
treatment  cannot  be  adopted,  or  if,  as  may  happen  it  is 
not  found  to  agree,  other  means  must  be  resorted  to. 
Thus,  for  an  infant  under  six  months  old,  the  milk  must 
be  greatly  restricted  in  quantity  ;  or  if  the  child  be  much 
reduced  in  strength,  may  judiciously  be  excluded  at  first 
altogether  from  the  diet.  In  most  of  these  cases  milk  in 
any  form  appears  to  act  as  a  positive  irritant  to  the 
bowels,  fermenting  and  turning  acid  directly  it  is  swal- 
lowed. When  this  tendency  to  acid  fermentation  prevails 
it  will  be  hopeless  to  attempt  to  arrest  the  derangement 
so  long  as  the  milk  diet  is  persisted  with.  Our  first  care 
must  therefore  be  to  substitute  for  it  a  non-fermentable 
regimen,  and  our  chief  trust  should  be  placed  in  fresh 


DIET 


91 


whey,  weak  veal  or  chicken  broth,  and  barley-water.  The 
latter,  which  on  account  of  its  consistence  is  very  grateful 
to  babies,  may  be  mixed  with  an  equal  proportion  of  whey 
and  of  broth  alternately,  and  given  from  a  perfectly  clean 
feeding-bottle.  If  the  purging  be  severe,  the  mixture 
must  be  given  cold,  and  in  small  quantities  at  a  time.  In 
such  cases,  instead  of  using  the  feeding-bottle,  the  food 
should  be  given  with  a  teaspoon. 

By  the  above  means  a  certain  variety  can  be  introduced 
into  the  diet ;  and  the  successive  meals  should  be  so  regu- 
lated that  the  quantity  taken  on  each  occasion,  and  the 
length  of  the  intervals  by  which  the  meals  are  separated 
may  be  properly  proportioned  to  one  another  and  to  the 
state  of  the  patient.  The  more  copious  the  diarrhoea,  the 
smaller  should  be  the  meals,  and  the  more  frequently  they 
should  be  repeated ;  for  any  large  quantity  of  liquid  food 
taken  at  once  would  be  directly  absorbed  from  the  stomach 
into  the  circulation,  and,  when  the  purging  is  severe, 
would  by  lowering  the  density  of  the  blood,  be  immediately 
followed  by  an  increase  in  the  flow  from  the  bowels.  When 
the  stools  are  frequent  and  watery,  liquids  should  never  be 
given  in  larger  quantities  than  a  tablespoonful  at  a  time, 
and  in  bad  cases  one  teaspoonful  will  be  found  sufficient. 

Beyond  the  age  of  six  months  the  yolk  of  one  egg  un- 
boiled may  be  added  to  the  diet.  The  egg  is  best  digested 
when  beaten  up  with  a  few  drops  of  brandy  and  a  table- 
spoonful  of  cinnamon-water.  As  with  younger  infants, 
the  quantities  to  be  given  at  one  time  must  depend  upon 
the  strength  of  the  child  and  the  state  of  his  bowels.. 

Farinaceous  food,  with  the  exception  of  barley-water, 
seldom  agrees  in  these  cases  ;  but  if  the  child  be  over 
twelve  months  old,  and  the  purging  not  very  severe,  we 
may,  if  desired,  make  cautious  trial  of  baked  or  boiled 
flour,  giving  one  teaspoonful  with  four  ounces  of  milk 
and  water.  One  of  the  malted  foods  is,  however,  to  be 
preferred  to  unguarded  farinaceous  matter,  especially  the 


92 


CHRONIC  DIARRHCEA 


form  known  as  Mellin's  food.  This  is  very  useful,  and 
can  be  given  dissolved  in  whey,  barley  water,  or  a  mixture 
of  both,  or  in  thin  veal  broth. 

As  the  child  improves,  milk  should  always  be  returned 
to,  but  at  first  should  be  given  with  a  sparing  hand,  for 
fear  it  should  disagree.  A  good  scale  of  diet  for  a  child 
of  nine  months  old,  who  is  beginning  gradually  to  return 
to  milk  food,  is  the  following,^  consisting  of  five  small 
meals  in  the  twenty-four  hours  : — 

1st  meal. — One  teaspoonful  of  Mellin's  Food  for  In- 
fants dissolved  in  four  ounces  of  sterilised  milk 
and  fresh  barley-water,  equal  parts. 

2nd  meal. — Four  ounces  of  veal  broth,  of  the  strength 
of  a  pound  of  meat  to  the  pint  of  broth. 

3rd  meal. — Four  ounces  of  fresh  whey,  containing  a 
dessertspoonful  of  cream. 

4th  meal. — The  unboiled  yolk  of  one  egg — plain,  or 
beaten  up  with  a  tablespoonful  of  cinnamon- 
water,  a  little  white  sugar,  and  ten  drops  of 
brandy. 

5th  meal. — Same  as  the  first. 

In  this  dietary  the  first  and  fifth  meals  contain  a  small 
quantity  of  milk.  It  is  best  to  assist  digestion  by  allow- 
ing only  milk  which  has  been  previously  sterilised  or 
peptonised  (see  page  46).  If  this  be  found  to  disagree, 
the  Mellin's  food  may  be  dissolved  in  barley  water,  alone 
or  diluted  with  an  equal  quantity  of  weak  veal  broth,  or 
weak  veal  broth  alone  may  be  given.  In  any  case,  the 
quantity  of  four  ounces  should  not  be  exceeded,  for  it  is 
wise,  especially  at  the  first,  to  be  sparing  rather  than 
liberal  in  regulating  the  allowance  of  food.  It  is  better 
that  the  child  should  be  hungry  than  overloaded  ;  and  so 
long  as  the  stools  retain  their  pasty  character  it  is  evident 

*  See  also  Diets  14,  15,  Ifi,  and  17,  Chap.  XI. 


DIET 


93 


that  the  food  taken  remains  in  great  part  undigested. 
In  these  cases,  and,  indeed,  in  all  cases  where  a  special  diet 
is  recommended  for  children,  a  dietary,  as  given  above 
should  be  written  out  by  the  medical  attendant  for  the 
benefit  of  those  to  whose  care  the  child  is  entrusted.  No, 
only  the  kind  of  food,  but  the  quantity  to  be  given  at  each 
meal,  and  even  the  hour  at  which  the  meal  is  to  be  taken, 
should  be  duly  set  down,  so  that  no  excuse  may  be  avail- 
able for  neglect  or  misapprehension. 

Whatever  be  the  diet  adopted,  our  object  is  to  keep  up 
the  nutrition  of  the  body  with  the  smallest  amount  of 
irritation  to  the  alimentary  canal ;  and  the  food,  whatever 
it  may  be,  which  will  produce  this  result,  is  the  food  best 
suited  to  the  case.  Without  attention  to  this  point,  all 
treatment  by  drugs  is  useless,  for  a  lump  of  indigestible 
food  will  neutralize  the  effect  of  the  most  powerful  astrin- 
gents. The  successful  adjustment  of  the  diet — an  adjust- 
ment in  which  the  quality  and  quantity  of  food  allowed 
for  each  meal  are  accurately  adapted  to  the  powers  and 
requirements  of  the  patient — is  a  matter  which  can  be 
properly  learned  only  by  experience,  and  which  often  makes 
large  demands  upon  the  tact,  the  ingenuity,  and  the  patience 
of  the  medical  attendant.  This  experience  every  one  should 
labour  to  acquire,  for  without  it  success  can  seldom  be 
attained  in  the  treatment  of  the  chronic  functional  derange- 
ments of  young  children. 

In  the  case  of  children  between  eighteen  months  and 
two  years  old  the  derangement,  as  has  been  said,  often 
begins  insidiously.  The  bowels  are  relieved  once  or 
oftener  in  the  day,  but  can  hardly  be  said  to  be  relaxed. 
The  stools  consist  of  light-coloured,  pasty  matter,  which  in 
exceptional  cases  may  even  be  formed.  They  are  always 
large,  and  are  usually  offensive.  In  this  form  of  the 
derangement  milk  must  be  strictly  excluded  from  the  diet, 
and  the  quantity  of  starchy  matter  taken  must  be  consider- 
ably reduced.    Instead  of  ordinary  bread,  the  child  must 


94 


CHRONIC  DIARRHOEA 


take  malted  bread  or  rusks  or  thin  dry  toast.  Mellin's 
food  is  useful,  made  thick  with  whey.  If  desired,  it  may 
be  flavoured  with  cocoatina.  For  dinner  the  child  may 
take  meat  jelly,  strong  veal  or  chicken  broth,  or  pounded 
raw  meat,  made  as  directed  on  a  later  page  (see  page  102). 
Yolk  of  egg  often  agrees  well,  and  may  be  given  lightly 
boiled,  or  beaten  up  with  a  teaspoonful  of  brandy. 

One  of  the  disadvantages  connected  with  this  method 
of  feeding  is  that  after  a  time  the  child  is  apt  to  suffer 
from  monotony  of  diet  and  absence  of  fresh  food.  The 
blood  becomes  deteriorated  in  quality,  and  symptoms  of 
scurvy  may  show  themselves.  On  this  account  fresh 
vegetable  food^  should  be  always  included  in  the  diet. 
Spanish  onion, f  flower  of  broccoli,  vegetable  marrow,  or 
young  French  beans,  may  be  given.  Each  of  these  must 
be  well  boiled  until  thoroughly  tender,  and  afterwards 
passed  through  a  sieve.  Every  care  should  be  taken  to 
vary  the  diet  as  much  as  possible,  as  the  patient  soon 
tires  of  his  food,  and  may  lose  his  appetite  in  conse- 
quence. Finely-ground  lentils,  sold  under  the  name  of 
"  Revelenta  Arabica,"  will  be  found  a  useful  resource,  and 
are  often  well  borne  if  prepared  with  a  third  part  of  finely 
ground  malt.  It  will  be  necessary  to  continue  the  diet  for 
many  months,  for  the  inability  to  digest  milk  and  starch 
often  continues  for  some  time  after  the  child  has  regained 
his  flesh  and  strength.  When  milk  is  returned  to,  it 
should  be  given  peptonised,  as  already  directed. 

In  the  case  of  older  children  who  share  the  ordinary 

^  If,  on  account  of  the  season  of  the  year,  fresh  vegetables  arc  diffi- 
cult to  obtain,  or  if  the  child  refuse  to  take  them,  a  teaspoonful  of 
fresh  lemon  juice  may  be  given  him  with  a  little  water  at  dinner  time. 
This  rarely  disagrees. 

t  These  onions  form  a  useful  addition  to  the  diet  of  young  chil- 
dren when  properly  cooked.  They  should  be  stewed  for  five  or  six 
hours,  changing  the  water  every  hour.  By  this  means  all  rankness  is 
left  behind,  and  the  vegetable  becomes  a  most  delicate  and  digestible 
article  of  diet. 


EXTERNAL  APPLICATIONS 


95 


meals  of  the  household,  it  will  be  necesary  also  to  make 
considerable  restrictions  in  the  amount  of  fermentable 
matter  allowed.  Potatoes,  sweet  biscuits,  and  farinaceous 
matters  generally,  sugar,  jams,  &c.,  should  be  excluded 
from  their  diet,  and  they  should  be  fed  upon  bread  and 
milk,  freshly-made  broths,  with,  at  dinner-time,  a  little 
fresh  meat  and  broccoli,  or  green  vegetables.  Puddings, 
as  a  rule,  should  be  forbidden,  but  custard  pudding  may 
be  permitted.  For  drink  they  should  take  toast-water, 
plain  water,  or  milk  and  water. 

The  abdomen  should  be  protected  by  a  broad  flannel 
bandage,  as  already  directed  for  infants.  Care  should  be 
taken  to  keep  the  feet  warm,  and,  unless  the  weather  be 
fine  and  dry,  the  child  should  be  confined  to  the  house. 

External  applications  are  exceedingly  useful  in  this 
disease,  for  the  secretion  of  the  skin  is  usually  suppressed 
at  an  early  period.  The  hot  bath  may  be  used  at  first 
every  night,  with  all  the  precautions  already  enjoined 
(see  page  13),  after  which  the  whole  body  should  be 
freely  anointed  with  warm  olive  oil,  and  the  child  be  well 
wrapped  up  in  flannel.  When  the  prostration  becomes 
marked  the  mustard- bath  may  be  ordered.  In  cases 
where  ulceration  of  the  bowel  is  suspected,  and  it  is 
thought  advisable  to  apply  local  counter- irritation,  a 
poultice  consisting  of  equal  parts  of  flour  of  mustard  and 
linseed- meal  should  be  used.  This  should  be  applied  at 
some  distance  from,  and  not  directly  over,  the  seat  of 
disease — to  the  chest,  and  not  immediately  to  the  belly ; 
and  its  effect  should  be  carefully  watched,  that  the  irrita- 
tion thus  excited  may  be  kept  within  due  bounds.  If 
the  child  is  very  weak,  the  mustard,  after  remaining  on  a 
few  minutes,  should  be  removed,  and  a  hot  poultice  of 
linseed-meal  should  be  applied  in  its  place.  When  the 
tenderness  of  the  abdomen  is  very  great  it  is  advisable  to 
keep  the  whole  belly  constantly  covered  with  a  large  hot 
linseed  meal  poultice.    This  must  be  changed  frequently^ 


96 


CHRONIC  DIARRHCEA 


but  with  great  care  that  the  child  be  not  chilled  in  the 
process. 

The  preceding  directions  embody  the  essential  points  in 
the  treatment  of  chronic  diarrhoea.  It  is  upon  the  judi- 
cious arrangement  of  his  food,  the  careful  protection  of 
his  body  from  fresh  chills,  and  the  plentiful  supply  of 
pure  air,  that  the  recovery  of  the  child  depends.  The 
question  of  drug-giving  is  one  only  of  secondary  import- 
ance. In  every  case,  therefore,  before  any  medicines  are 
prescribed,  the  above-mentioned  matters  must  be  attended 
to.  The  medical  attendant  should,  with  his  own  hands, 
apply  the  flannel  bandage  tightly  roimd  the  patient's  hips 
and  waist,  laying  the  child  down  for  the  purpose,  with  legs 
stretched  out,  so  that  the  flannel  may  be  brought  well  below 
the  projection  of  the  hips,  and  thus  be  prevented  from 
slipping  upwards. 

With  regard  to  internal  remedies  :^ — If  the  patient  is 
seen  at  the  first,  before  the  diarrhcea  has  become  esta- 
blished, and  when  there  is  nothing  but  pallor,  languor, 
gradual  loss  of  flesh,  griping  and  tenesmus,  with  large, 
pale,  sour-smelling  stools,  a  small  dose  of  powdered  rhu- 
barb, with  carbonate  of  soda,  should  be  ordered,  and 
then,  when  the  bowels  are  relieved,  a  mixture  containing 
tinct.  opii.  with  bicarbonate  of  soda  in  some  aromatic 
water : — 

5b    Tinct.  Opii,  gtta  j, 

SodsG  Bicarbonatis,  gr.  ij, 
Tinct.  Zingiberis,  r»tj, 

Aq.  Chloroformi  ad  5j.    M.    Ft.  liaustus. 
To  be  taken  three  times  a  day. 

The  opium  at  once  renders  the  peristaltic  action  of  the 
bowels  more  regular,  and  the  stools  become  darker  and 
less  offensive  in  the  course  of  a  few  days. 

The  mixture  containing  tinct.  opii.  and  castor  oil,  is 
also  very  useful  if  the  tongue  is  furred  : — 

*  All  the  prescriptions  given  in  this  section  are  adapted  to  a  child 
of  twelve  months  old,  unless  otherwise  stated. 


DIGESTIVES 


97 


p,    Tinct.  Opii,  gtta.  j, 
01.  Ricini, 
Glycerini, 

Mucilag.  Acaciae,  aa  nw, 
Aq.  ad  3j.  M. 
To  be  taken  three  times  a  day. 

But  it  should  not  be  used  if  the  tongue  is  clean,  and  must 
not  be  continued  longer  than  forty-eight  hours  if  no  benefit 
be  found  to  result  from  its  employment. 

Alteratives  are  in  these  cases  of  little  value,  for  it  is  no 
use  attempting  to  stimulate  the  functions  of  the  liver  by 
cholagogues.  The  large  white  putty-like  stools  consist,  in 
great  part,  of  undigested  food ;  and  we  shall  best  succeed 
in  restoring  the  digestive  power  by  antacids  and  aromatics, 
as  directed  above,  and  more  than  all,  by  the  careful 
adaptation  of  the  food,  both  in  quantity  and  quality 
to  the  enfeebled  powers  of  the  child.  It  is  in  these 
cases  that  milk  is  seldom  well  borne,  except  in  very 
small  doses  well  diluted  with  lime-water,  and  it  is  often 
necessary  to  replace  this  by  other  articles  of  diet  as  already 
described. 

Sometimes  these  patients  are  greatly  benefited  by  the 
administration  of  extract  of  malt,  directly  after  each  meal. 
If  the  bowels  are  not  relaxed,  malt  extract  is  usually  well 
borne,  but  in  some  children  it  has  an  aperient  action  which 
is  injurious.  Pepsine  is  another  useful  digestive.  Three 
to  five  grains  given  to  a  child  of  eighteen  months  or  two 
years  old,  with  a  drop  or  two  of  dilute  hydrochloric  acid 
and  one  of  laudanum,  directly  before  each  meal,  will  be 
found  of  service.  The  dose  of  pepsine  should  be  always 
combined  with  a  small  quantity  of  laudanum,  so  that  the 
passage  of  food  along  the  bowel  may  be  sufficiently  delayed 
to  give  the  digestive  time  to  exert  its  influence. 

Finkler's  papain  is  a  digestive  of  even  greater  value. 
It  should  be  given  in  combination  with  an  alkali,  as  in 
the  following: — 

7 


98 


CHRONIC  DIARRHOEA 


Jto    Papain  (Finkler),  gr.  ss, 
SodjB  Bicarb.,  gr.  ij, 
Pulv.  Trochisci  Menth.  Pip.,  gr.  iij. 
M.    Ft.  pulv. 

To  be  taken  three  times  a  day  just  before  food. 

When  the  purging  sets  in,  if  the  stools  are  green,  and 
slimy  or  watery,  with  a  sour  smell,  it  is  best  to  begin  with 
a  dose  of  bismuth  and  chalk.  To  be  of  service  the  dose 
of  bismuth  must  be  a  large  one.  The  remedy  is  not 
absorbed  into  the  circulation,  and  may  be  therefore  given 
in  large  quantities  to  the  youngest  children  without  any 
danger. 

1^    Bismuthi  Carb.,  gr.  x, 

Pulv.  Cretse  Aromat.,  gr.  ij. 
M.    Ft.  pulv. 
To  be  taken  every  four  hours. 

If  there  is  much  tenesmus,  an  injection  containing  four 
or  five  drops  of  laudanum,  with  five  grains  of  bicarbonate 
of  potash,  to  half  an  ounce  of  thin  warm  starch  may  be 
thrown  up  the  bowel.  Dr.  Evanson  strongly  recommends 
the  addition  of  the  alkali,  which,  he  says,  greatly  increases 
the  efficacy  of  the  injection. 

So  long  as  the  stools  remain  sour- smelling,  antacids 
should  be  persisted  with.  An  aromatic  should  always  be 
combined  with  the  antacid.  This,"  says  Dr.  Underwood, 
''is  of  more  importance  than  is  usually  apprehended.  I 
have  known  a  careful  attention  to  this  circumstance  alone 
happily  suppress  complaints  in  the  bowels,  which  had  long 
continued  obstinate,  though,  in  other  respects,  properly 
treated."  In  these  cases,  too,  an  emetic  is  often  of  great 
service. 

It  is  necessary  to  inspect  the  stools  daily  for  signs  of 
mucus  or  any  increase  in  the  looseness.  Usually,  in  spite 
of  all  possible  care,  the  motions  will  be  found  every  now 
and  then  to  be  loose  and  slimy.  When  this  occurs  a 
powder  containing  two  or  three   grains   of  powdered 


f 


ASTRINGENTS  99 

rhubarb  and  double  the  quantity  of  aromatic  chalk 
powder  should  be  given  every  night,  and  in  the  daytime 
the  child  may  take  the  castor  oil  and  opium  mixture 
already  recommended.  By  this  means  the  state  of  the 
bowels  will  be  greatly  improved  in  the  course  of  a  few 
days. 

If,  when  the  tongue  cleans,  the  diarrhoea  continues,  and 
the  stools  are  found  to  consist  of  dirty-brown  stinking 
water,  astringents  must  be  used. 

The  best  of  these,  without  any  doubt,  is  nitrate  of 
silver.  One-eighth  of  a  grain  should  be  given  with  one 
drop  of  dilute  nitric  acid  and  one  drop  of  laudanum 
in  aqua  chloroformi  every  four  hours.  This  remedy  is 
valuable  in  all  forms  of  chronic  intestinal  catarrh  in 
children,  but  is  especially  useful  in  cases  where  the  stools 
are  very  frequent  and  watery,  and  contain  variously 
coloured  mucous  and  blood  ;  or  where  the  prostration  is 
great,  with  aphthous  ulceration  of  the  mouth.  In  such 
cases  it  should  be  always  resorted  to. 

The  ordinary  astringents  seem  of  little  service ;  and  in 
many  children  gallic  acid,  dilute  sulphuric  acid,  lead, 
hsematoxylon,  and  other  similar  remedies  may  be  given 
perseveringly  without  producing  any  impression  upon 
the  derangement.  Bismuth,  however,  in  large  doses 
(gr.  X — XV  to  a  child  of  twelve  months  old  every  three 
or  four  hours)  will  often  check  the  diarrhoea  at  once, 
especially  if  given  with  aromatic  chalk  powder,  as  already 
recommended ;  but  the  improvement  is  sometimes  only 
temporary. 

Injections  of  nitrate  of  silver  are  valuable  in  the  later 
stages,  particularly  if  there  are  any  signs  of  ulceration  of 
the  large  intestine.  The  bowel  should  be  first  cleared  out 
with  warm  water,  and  then  an  enema,  containing  one 
grain  of  the  nitrate  to  five  ounces  of  cold  water,  should 
be  administered.  Trousseau  recommends  that  in  bad 
cases  it  should  be  repeated  twice  in  the  twenty-four  hours. 


100 


CHRONIC  DIARRHCEA 


Astringent  enemata  must  not,  however,  be  continued  too 
long.  They  should  be  suspended  every  two  or  three  days 
in  order  to  watch  the  effect,  and  in  the  interval  enemata 
of  simple  starch  may  be  used. 

The  perchloride  of  mercury  is  a  useful  remedy  in  cases 
where  very  slimy  motions  are  passed  with  much  straining 
and  pain,  especially  if  lumps  of  coagulated  mucus,  com- 
pared by  the  attendants  to  "  lumps  of  flesh,"  are  found 
in  the  stools.  Three  to  five  drops  of  the  pharmacopoeia 
solution  may  be  given  in  water  every  hour  or  two  hours 
sweetened  with  spirits  of  chloroform. 

Stimulants  will  be  required  as  the  child  grows  weaker, 
and  must  be  given  pretty  freely  when  the  sinking  of  the 
fontanelle  and  the  other  symptoms  show  that  he  is  be- 
coming exhausted.  Five  or  ten  drops  of  pale  brandy,  or 
double  the  quantity  of  dry  pale  sherry,  may  be  given  in  a 
spoonful  of  the  food  three,  four,  or  six  times  a  day,  or 
even  every  hour,  as  required.  Grood  beef  gravy  free  from 
fat,  is  also  useful  at  these  times. 

Not  seldom,  in  spite  of  all  our  efforts,  the  child  goes 
on  from  bad  to  worse.  The  diarrhoea  resists  all  treat- 
ment, and  continues  obstinate,  whatever  be  the  measures 
adopted.  In  these  cases  the  treatment  by  raw  meat 
becomes  a  valuable  resource.  A  piece  of  raw  mutton  free 
from  gristle  or  fat,  is  finely  minced,  and  is  pounded  in  a 
mortar  till  it  is  converted  into  a  pulp.  The  pulp  is  then 
rubbed  through  a  fine  sieve,  to  remove  the  blood-vessels 
and  cellular  tissue.  Of  the  meat  so  prepared  a  teaspoonful 
is  given  at  regular  intervals  four  times  in  the  day,  and 
every  day  the  quantity  administered  is  gradually  increased, 
until  half  a  pound  is  taken  each  day  in  divided  doses.  If 
the  taste  of  raw  meat  is  greatly  objected  to,  a  thick 
mutton  chop  may  be  grilled  quickly  over  a  hot  fire.  Of 
this,  the  hardened  outside  is  to  be  cut  away  and  the  soft 
juicy  interior  alone  made  use  of  for  the  meal.  The  meat 
usually  at  first  causes  the  motions  to  have  an  intensely 


POUNDED  RAW  MEAT 


101 


offensive  smell ;  but  this  is  of  no  consequence,  and  the 
parents  should  be  warned  of  its  liability  to  occur.  The 
patients  themselves  often  like  the  food,  and  take  it  eagerly. 
If,  however,  as  may  happen,  they  show  any  repugnance  to 
it,  the  meat  may  be  given  in  a  small  quantity  of  veal 
broth,  may  be  diffused  through  jelly,  or  may  be  mixed 
with  an  equal  quantity  of  cream,  if  the  latter  can  be 
obtained  perfectly  fresh.  As  medicine,  we  must  give  at 
the  same  time  the  pepsine  mixture,  already  recommended, 
with  the  addition  of  one  drop  of  tinct.  opii  to  each  dose. 
There  can  be  no  doubt  about  the  value  of  this  remedy. 
Under  its  influence  the  stools  become  less  frequent  and  less 
liquid,  and  although  they  remain  for  a  time  horribly  foetid, 
yet  they  gradually  assume  more  and  more  the  character  of 
healthy  evacuations,  while  the  other  symptoms  undergo  a 
like  amendment.  For  the  first  day  or  two  the  meat  will 
be  found  in  the  motions  almost  unchanged,  except  for 
decomposition,  the  dejections  consisting  of  colourless 
fibrine  with  a  little  cellular  tissue  and  mucus  ;  but  by 
perseverance  we  find  that  it  begins  gradually  to  be  digested 
and  less  of  it  appears  every  day  in  the  stools. 

When  from  this  or  other  treatment  the  diarrhoea  has 
been  arrested,  and  the  stools  have  become  more  healthy- 
looking,  a  tonic  should  be  given,  and  the  one  best  adapted 
to  continue  the  improvement  is  the  solution  of  the  perni- 
trate  of  iron,  which  has  besides  a  beneficial  influence  upon 
the  alimentary  canal.  It  is  best  given  with  dilute  nitric 
acid : — 

Liq.  Ferri  Pernitratis,  rrtj, 
Acidi  Nitrici  diluti,  inja 
Glycerini,  itlv, 

Aquam  Anetlii  ad  53.    M.    Ft.  haustus. 
To  be  taken  every  six  hours. 

Other  tonics  may  afterwards  be  given,  as  the  decoction 
of  bark  with  syrup,  the  citrate  of  iron  and  quinine,  cod- 
liver  oil,  &c.    If  the  oil  be  given,  its  effects  must  be  care- 


102 


CHRONIC  DIARRHCEA 


fully  watched.  It  is  best  to  begin  with  a  small  dose,  as 
ten  drops  in  a  teaspoonful  of  food  three  times  in  the  day ; 
but  if  there  be  any  smell  of  the  oil  in  the  stools,  even  this 
small  quantity  must  be  diminished.  The  constipation, 
which  usually  succeeds  to  the  diarrhoea,  should  not  be 
lightly  interfered  with.  If  two  or  three  days  have  passed 
without  any  action  of  the  bowels,  a  very  small  dose— about 
twenty  drops —of  castor  oil  may  be  administered,  and  may 
be  repeated,  if  necessary,  after  four  or  five  hours. 

As  so  much  harm  is  often  done  in  these  cases  of  chronic 
diarrhoea  by  little  indiscretions,  it  is  of  extreme  importance 
that  we  should  not  allow  improvement  to  make  us  relax  in 
our  attention  or  diminish  our  precautions.  It  is  a  good 
rule  in  all  cases  where  the  child  is  getting  better  to  act  as 
if  he  were  getting  worse,  to  redouble  our  vigilance  rather 
than  to  relax  in  it ;  for  at  any  time  a  chill  or  a  fragment 
of  indigestible  food  may  undo  all  that  has  been  done,  and 
throw  the  child  back  into  a  state  from  which  it  has  required 
perhaps  months  of  care  to  deliver  him. 

After  the  cessation  of  the  diarrhoea  the  child  must  not, 
however,  be  kept  too  low.  As  his  digestive  power  in- 
creases, his  diet  should  be  improved  in  proportion.  This 
is  very  important,  as  rickets  is  not  an  uncommon  result  of 
the  impairment  of  nutrition  produced  by  the  disease,  and 
is  therefore  favoured  by  anything  which  tends  to  prolong 
the  weakly  condition  of  the  infant. 

In  patients  of  three  or  four  years  old  and  upwards 
chronic  diarrhoea  usually  excites  less  anxiety  than  in 
younger  children,  and  responds  more  readily  to  treatment. 
If  the  diet  be  regulated  upon  the  plan  previously  laid 
down  (see  p.  90),  and  a  flannel  bandage  be  properly 
applied  to  the  belly,  recovery  usually  follows  quickly 
enough.  For  medicines  the  child  may  take  an  alkaline 
mixture,  containing  two  or  three  drops  of  laudanum,  and 
every  other  night  for  a  week,  a  powder  containing  four  to 
six  grains  of  powdered  rhubarb,  with  twice  the  quantity 


LIENTERIC  DIARRHCEA 


103 


of  aromatic  chalk  powder.  Should  the  diarrhoea  still  per- 
sist, five  drops  of  tincture  of  catechu  in  a  teaspoonful  of 
mucilage  every  hour,  or  a  mixture  containing  gallic  acid, 
dissolved  in  aromatic  sulphuric  acid,  may  be  resorted  to. 

The  lienteric  diarrhoea  previously  described,  in  which  the 
evacuations  occur  frequently  after  a  meal,  and  consist  of 
undigested  food,  requires  a  different  kind  of  treatment. 
This  variety  of  diarrhoea  is  not  to  be  controlled  by  the 
ordinary  astringents,  and  is  very  much  increased  by 
aperients,  as  castor  oil.  Opium  will,  however,  sometimes 
check  it  temporarily,  but  for  its  permanent  cure  the  best 
remedies  are  arsenic  and  tincture  of  nux  vomica  in  small 
doses. 

The  following  short  cases  will  serve  as  illustrations  of 
this  form  of  diarrhoea,  and  of  the  treatment  to  which  it  is 
most  readily  amenable:  — 

Master  R.,  aged  five  years,  had  been  subject  for  twelve 
months  to  prolonged  attacks  of  diarrhoea,  during  which 
the  bowels  acted  four  or  six  times  in  the  day.  The  motions 
usually  followed  a  meal,  and  sometimes  so  urgently  that 
he  was  obliged  to  leave  the  table  before  the  repast  was 
concluded.  The  motions  were  said  to  run  from  him," 
and  to  contain  much  slimy  matter.  There  was  no  strain- 
ing, but  the  stools  were  preceded  by  some  griping  pains  in 
the  belly.  He  was  fretful  and  rather  thirsty,  but  slept 
well  at  night.  He  was  losing  flesh  rapidly,  although  his 
appetite  was  large.  The  child  was  ordered  to  take  two 
drops  of  tincture  of  nux  vomica  in  a  draught  of  citrate  of 
potash  three  times  a  day  before  meals.  A  few  days  after- 
wards he  returned  very  much  better.  The  bowels  were 
acting  three  times  a  day,  not  after  meals.  His  appetite 
was  more  easily  satisfied,  and  he  had  ceased  to  waste.  A 
change  was  then  made  in  his  medicine  to  one  drop  of  liq. 
arsenici  chlor.  in  a  nitric  acid  mixture  before  each  meal, 
and  he  was  not  seen  again. 

Elizabeth  W.,  aged  four  years,  had  suffered  for  a  long 


104 


CHRONIC  DIARRHCEA 


time  from  repeated  attacks  of  diarrhoea,  each  of  which 
lasted  for  many  weeks  together.  The  motions  were  said 
to  follow  immediately  upon  taking  food,  and  to  occur 
sometimes  in  the  intervals  between  the  meals,  so  that  the 
bowels  were  frequently  acted  upon  five  or  six  times  in  the 
day.  The  stools  were  slimy,  and  were  passed  without 
straining  or  apparent  discomfort.  The  child  was  irritable 
in  temper,  and  was  very  restless  at  night.  Her  appetite 
was  capricious,  and  she  was  very  fanciful  in  her  eating. 
Her  skin  was  exceedingly  rough  and  dry.  The  tongue 
was  clean,  and  over  the  surface  were  scattered  light-red 
elevated  papillae.  She  was  first  seen  on  January  7th,  and 
was  ordered  to  take  one  drop  of  liq.  arsenicalis  in  a  mix- 
ture containing  citrate  of  iron  and  ammonia,  with  bicar- 
bonate of  soda,  three  times  a  day.  A  warm  bath  was 
recommended  every  night,  for  the  purpose  of  softening 
the  skin  and  removing  the  dry  epithelium  scales. 

On  January  14th  the  girl  seemed  better  in  herself, 
although  the  bowels  were  in  the  same  condition  as  before. 
She  had  taken  the  medicine  regularly,  but  each  meal  was 
still  followed  by  the  accustomed  stool,  and  the  child  was 
still  losing  flesh.  A  mixture  was  then  ordered  containing 
laudanum  and  tincture  of  nux  vomica — two  drops  of  each 
to  be  taken  before  every  meal.  Considerable  improvement 
followed  the  change  of  medicine  :  the  appetite  became  very 
good,  and  the  bowels,  although  still  relaxed  after  each 
meal,  did  not  act  in  the  intervals,  so  that  the  daily 
number  of  evacuations  was  much  reduced.  The  skin, 
owing  to  the  nightly  warm  bath,  had  become  soft  and 
supple.  One  drop  of  liq.  arsenici  chlor.  was  then  given 
three  times  a  day  in  a  nitric  acid  mixture,  and  the  cure 
was  soon  complete. 


CHAPTER  III 


CHRONIC  VOMITING 
(chronic  gastric  catarrh) 

SLIGrHT  attacks  of  vomiting,  lasting  for  twenty-four 
hours,  or  even  for  several  days,  are  not  at  all  un- 
common in  infants  even  while  at  the  breast.  The  matters 
ejected  consist  of  the  food,  of  stringy  mucus,  and  of  bile ; 
at  the  same  time  there  is  some  heat  of  skin,  thirst,  loaded 
tongue,  and  constipation  or  diarrhoea.  These  attacks,  due 
to  an  acute  catarrh  of  the  stomach,  always  end  favourably 
unless  they  are  aggravated  by  much  meddling.  The  only 
treatment  required  is  an  emetic  of  ipecacuanha  wine  to 
relieve  the  stomach,  followed  by  a  gentle  purge,  and  by 
careful  regulation  of  the  diet.  Sometimes  it  is  necessary 
to  forbid  even  the  breast-milk  for  a  time,  and  to  restrict 
the  infant  to  cold  thin  barley-water  given  with  a  teaspoon. 

These  attacks  are  of  little  consequence.  The  child  may 
get  a  little  flabby  and  pale,  but  when  convalescent  a  week 
of  ordinary  feeding  restores  him  to  his  former  state  of 
health.  The  catarrh  may,  however,  pass  into  a  subacute 
stage,  which  is  much  more  serious,  and  the  vomiting  then 
becomes  chronic  and  persistent.  This  condition  is  often  a 
very  dangerous  one,  and  always  produces  great  wasting 
and  prostration. 

Symptoms. — There  is  no  fever.  The  child  vomits  at 
irregular  intervals,  throwing  up  the  milk  curdled  and 
sour- smelling,  and,  at  the  first,  tinged  green  or  yellow  from 
bile.  The  bile,  however,  soon  disappears  from  the  vomited 
matters,  and  clear  fluid,  like  water,  is  ejected,  alone  or 
mixed  with  the  food.    On  pressure  of  the  epigastrium  the 


106 


CHRONIC  VOMITING 


child  writhes  as  if  in  pain.  The  belly  is  full,  often  tympa- 
nitic, and  gurgles  when  pressed  upon.  Eructations  occur 
of  foetid,  sour  gas,  and  the  bowels  are  obstinately  confined. 
An  eruption  of  strophulus  often  covers  the  body  and  arms, 
and  the  complexion  has  often  a  sallow,  half -jaundiced  tint. 
The  child  gets  thinner  and  paler,  and  is  very  fretful.  The 
fontanelle  becomes  depressed.  Some  diarrhoea  may  at 
first  alternate  with  the  constipation,  but  after  a  few  days 
the  bowels  become  again  confined,  and  the  motions,  when 
they  occur,  consist  of  round,  hard  lumps,  very  light- 
coloured,  evacuated  with  great  straining.  The  lumps  may 
be  covered  with  tough  mucus.  The  tongue  is  coated  with 
a  thick  layer  of  dirty-yellow  fur ;  it  is  not  very  moist,  and 
dull  red  papillae  of  medium  size  are  seen  peering  through 
the  fur,  here  and  there,  on  the  dorsum  of  the  tongue. 
The  breath  smells  sour.  The  lips  are  dry  and  red.  A 
furrow  passes  down  from  each  side  of  the  nose  to  encircle 
the  corner  of  the  mouth,  so  that  the  lips  seem  to  project. 
The  mouth  is  clammy  and  pai^ched,  and  the  child  takes 
the  breast  eagerly  to  relieve  this  parched  feeling  by  the 
flow  of  milk,  but  rejects  what  he  has  swallowed  very 
shortly  afterwards. 

After  the  child  has  remained  in  this  state  for  a  con- 
siderable time,  often  with  occasional  intervals  of  improve- 
ment for  several  months,  the  vomiting  becomes  more 
frequent.  It  occurs  not  only  after  taking  food,  but  also 
in  the  intervals  of  feeding,  and  seems  to  be  excited  by  the 
slightest  movement,  or  by  a  touch,  so  that  the  mere  act  of 
wiping  the  mouth  may  bring  on  a  fresh  attack  of  retching. 
The  milk  is  thrown  up  uncurdled.  Emaciation  then  goes 
on  rapidly.  The  skin  is  dry  and  harsh,  and  hangs  loose 
and  flaccid ;  the  eyes  get  hollow  ;  the  nose  sharpened  ;  the 
cheeks  sunken ;  and  the  belly  retracted.  He  lies  with  the 
knees  drawn  up  on  to  the  abdomen,  and,  when  they  are 
straightened  out,  returns  them  as  soon  as  possible  to  their 
former  position.    Occasionally  he  moves  his  legs  uneasily. 


SPURIOUS  HYDROCEPHALUS 


107 


as  if  in  pain.  He  is  intensely  fretful,  breaking  out  into 
sudden  cries,  or,  as  lie  becomes  weaker,  into  a  low,  pitiful 
wail,  which  is  even  more  distressing  to  hear,  and  never  . 
seems  to  sleep,  night  nor  day.  The  tongue  is  dry,  and  is 
still  furred,  so  that  it  has  a  rough,  granular  appearance. 
In  bad  cases  the  whole  body  has  an  offensively  sour  smell. 
The  smell  j)roceeds  not  only  from  the  breath,  but  is  caused 
by  acidity  of  all  the  secretions ;  the  saliva,  the  perspira- 
tion, and  the  urine  being  all  intensely  acid.  The  cutaneous 
secretion  is,  however,  seldom  in  excess ;  more  usually  the 
skin  is  inelastic  and  dry,  and  is  in  consequence  rough  and 
harsh  to  the  touch,  especially  at  the  back  of  the  arms  and 
the  belly. 

At  length  the  child  reaches  a  pitiable  state  of  emacia- 
tion, and  his  strength  is  reduced  to  its  lowest  point.  It 
is  at  this  time  that  symptoms  which  have  been  called 
''spurious  hydrocephalus"  often  make  their  appearance. 
The  child  sinks  into  a  drowsy  state,  and  lies  quietly  upon 
his  back  with  his  eyes  showing  white  between  his  half- 
closed  purple  eyelids.  The  pupils  are  slaggisli,  and  per- 
haps unequal ;  the  pulse  is  rapid  and  often  intermittent ; 
the  breathing  is  irregular ;  the  fontanelle  is  deeply  de- 
pressed ;  an  earthy  tint  may  spread  over  the  whole  body, 
and  the  face,  hands,  and  feet  are  livid  or  lead-coloured. 
Warmth  can  be  kept  in  the  limbs  only  by  cotton  wool  and 
hot  bottles,  and  the  rectal  temperature  is  subnormal.  At 
first  the  child  may  open  his  eyes  now  and  then  sleepily,  as 
if  not  completely  unconscious,  but  he  seems  unable  to 
swallow,  and  soon  passes  into  a  state  of  decided  coma. 
When  thrush  is  noticed  on  the  inside  of  the  cheeks  and 
lips  it  is  a  sign  that  the  end  is  near ;  and  death  is  often 
preceded  by  faint  convulsive  movements. 

The  terminal  symptoms  thus  described  are  not  peculiar 
to  chronic  vomiting,  although  they  are  especially  apt  to 
occur  with  that  disease.  They  may  be  found  in  all  cases 
where  great  exhaustion  is  induced  from  whatever  cause, 


108 


CHRONIC  VOMITING 


and  are  therefore  not  uncommon  in  chronic  diarrhoea. 
In  all  these  cases  the  fontanelle  is  deeply  depressed, 
showing  deficiency  in  the  amount  of  blood  circulating 
through  the  brain;  the  pupils  are  often  dilated  and  im- 
movable, and  there  may  be  coma,  with  stertorous  breath- 
ing. It  must  not,  however,  be  concluded  that  cerebral 
symptoms  occurring  in  a  wasted,  feeble  infant  are  the 
consequence  merely  of  sluggish  circulation  through  the 
brain  of  impoverished  blood.  Parrot  compared  the  con- 
dition to  uraemia,  and  noticing  the  diminished  secretion  of 
urine  observed  when  such  cerebral  symptoms  are  present, 
suggested  a  toxic  origin  for  the  phenomena.  More  recent 
observations  tend  to  support  the  conclusion  that  cerebral 
symptoms  and  even  cerebral  lesions  may  be  set  up  during 
g astro-intestinal  derangements  by  toxic  products.  Marfan 
refers  squinting,  opisthotonos,  and  drowsiness  to  the  action 
of  microbes  or  microbial  poisons,  and  asserts  that  the 
thrombi  and  intra- cranial  haemorrhages  may  also  be  the 
consequence  of  toxi-infective  processes  of  gastro-intestinal 
origin.  From  whatever  cause  they  may  proceed,  there 
can  be  no  doubt  that  the  symptoms  are  of  most  unfavour- 
able augury,  and  show  the  condition  of  the  child  to  be 
perilous  in  the  extreme. 

In  cases  of  recovery  the  vomiting  becomes  less  frequent, 
and  gradually  ceases,  although  for  some  time  it  is  liable 
to  recur  if  much  food  be  taken  at  once.  The  constipation, 
however,  remains  obstinate  for  some  time  after  the  cessa- 
tion of  the  vomiting.  The  child  then  begins  to  regain 
flesh,  and  often  becomes  exceedingly  fat. 

Causes. — The  complaint  is  common  in  infants  of  a  few 
months  old  who  have  been  weaned  prematurely  and  fed 
with  a  diet  they  are  unable  to  digest.  Wet-nurses'  chil- 
dren are  often  subject  to  it ;  but  the  disorder  is  met  with 
in  all  ranks  of  life  when  the  infant's  food  is  ill  chosen  or 
given  without  due  care. 

A  not  uncommon  cause  of  repeated  vomiting  is  monotony 


CAUSES 


109 


of  diet ;  the  child  being  fed  morning,  noon,  and  night  on 
the  same  thing.  It  has  already  been  explained  (see  p.  42) 
that  in  many  hand-fed  infants  the  digestion  requires  the 
stimulus  of  variety,  and  resents  the  repetition  at  every 
meal  of  the  same  food  in  exactly  the  same  shape.  If  a 
change  be  made  to  another  food,  the  vomiting  stops  for  a 
few  days,  but  only  to  return  when  the  novelty  has  worn 
off,  and  the  new  food  has  ceased  to  please.  In  this  way 
the  derangement  goes  on  as  long  as  the  same  method  of 
feeding  is  persisted  with.  Each  change  is  followed  by 
immediate  improvement,  and  the  vomiting  ceases  until  the 
sameness  of  diet  once  more  becomes  wearisome,  when  the 
food  is  again  rejected  as  it  was  before. 

Cold  and  damp  are  also  fruitful  causes  of  this  complaint. 
The  curious  indifference  shown  by  mothers  to  the  warmth 
of  their  children's  feet  is  answerable  for  many  of  the 
illnesses  in  a  young  family,  and  for  not  a  few  of  the 
deaths.  Whatever  the  weather  may  be,  the  indoor  dress 
leaves  the  legs  bare  and  often  the  thighs  and  abdomen  as 
well.  Sturdy  children  may  endure  the  exposure  without 
obvious  harm  ;  but  frailer  subjects  are  often  kept  delicate 
and  ailing  by  this  means,  even  if  they  do  not  show  more 
serious  signs  of  illness.  Even  young  infants  still  in  their 
long  clothes  may  suffer  from  cold  feet  without  any  reso- 
lute effort  being  made  to  amend  their  condition.  The 
nurse  says  she  ''cannot  get  the  feet  warm,"  and  perhaps 
gives  up  all  attempts  to  do  so.  Children  who  suffer  in 
this  way  from  exposure  or  neglect  are  always  on  the  brink 
of  an  illness,  and  it  requires  but  a  mere  trifle,  such  as  a 
mild  additional  chill,  to  determine  the  outbreak. 

The  crowding  of  infants  together  in  close  nurseries, 
or  amongst  the  poor  the  stifling  atmosphere  of  the  one 
room  in  which  a  whole  family  is  often  lodged,  is  another 
common  cause  of  the  disorder. 

These  causes  have  already  been  fully  discussed  under 
the  head  of  chronic  diarrhoea. 


110 


CHRONIC  VOMITING 


Severe  operations  upon  the  child,  siich  as  that  for  stone 
in  the  bladder,  are  often  followed  by  an  acid  dyspepsia, 
which  may  lapse  into  obstinate  vomiting ;  a  chronic 
catarrh  of  the  stomach  and  bowels  being  set  up,  which 
may  lead  to  death  after  the  more  immediate  effects  of  the 
operation  have  been  recovered  from.  Any  cause,  in  fact, 
which  lowers  the  easily-depressed  general  strength  will 
reduce  also  the  digestive  power,  and  thus  predispose  to 
this  complaint. 

Drugging  with  opiates  by  an  unscrupulous  nurse  will 
sometimes  keep  up  persistent  vomiting  in  a  new-born  baby. 
Therefore,  if  we  find  the  pupils  to  be  contracted,  the  skin 
inelastic,  the  bowels  obstinately  costive,  and  notice  that 
the  child  is  unnaturally  drowsy  and  apathetic,  we  should 
suspect  such  a  cause  for  the  indisposition,  and  advise  very 
searching  inquiry. 

Diagnosis. — The  diagnosis  of  chronic  gastric  catarrh 
presents  little  difficulty.  The  frequent  vomiting  of 
offensive  sour  fluid,  the  emaciated  condition  of  the  child, 
and  the  long  course  of  the  complaint,  leave  little  room 
for  uncertainty.  If  the  combination  of  obstinate  vomiting 
with  constipation,  or  the  occurrence  of  cerebral  symjDtoms, 
should  give  rise  to  suspicions  of  acute  tuberculosis  with 
secondary  meningitis,  the  two  diseases  are  readily  dis- 
tinguished. The  temperature  of  the  body  depressed 
instead  of  being  elevated ;  the  sunken  f  ontanelle ;  the 
rapid,  feeble,  but  regular  pulse  ;  the  state  of  the  belly, 
swollen  rather  than  retracted — all  tend  to  exclude  the 
latter  disease. 

Treatment. — Our  first  care  must  be  to  see  that  the  child 
is  warmly  dressed  and  carefully  guarded  from  cold.  In 
the  early  stages  of  the  disorder  the  gastric  irritability  is 
maintained  from  day  to  day  by  repeated  chills.  The 
child  is  half  clothed  or  is  carelessly  exposed  in  his  bath. 
Examination  shows  that  the  feet  and  legs  are  bitterly  cold, 
and  on  enquiry  we  generally  find  that  the  child  is  being 


WARMTH 


111 


bathed  at  undue  length,  often  in  merely  tepid  water.  It 
is  important  to  explain  to  those  concerned  that  any  exist- 
ing catarrh  greatly  heightens  the  patient's  susceptibility  to 
changes  of  temperature,  and  that  an  impression  of  cold 
which  would  be  powerless  to  originate  a  catarrh  may  be 
amply  sufficient  to  keep  up  one  already  existing.  It  is  best 
to  forbid  the  bath  for  a  time,  and  allow  only  local  sponging, 
keeping  the  feet,  legs,  and  belly  well  wrapped  up  in  cotton- 
wool. It  is  advisable  that  the  physician  look  into  this 
matter  for  himself,  and  do  not  rest  satisfied  with  the  report 
of  the  nurse.  If  cotton- wool  be  applied,  he  should  see 
that  enough  of  it  is  put  on  to  effect  the  object  desired.  It 
is  not  merely  that  the  limbs  must  be  wrapped  up,  but  that 
they  must  be  made  and  kept  warm,  for  unless  this  prelimi- 
nary step  be  taken  no  treatment  can  succeed.  It  is  well 
while  the  vomiting  is  urgent,  to  confine  the  patient  to  one 
or  two  rooms  kept  as  nearly  as  possible  at  a  temperature  of 
65°  F.  Fresh  air  should  be  freely  admitted,  and  at  night, 
if  there  is  no  fire,  a  lamp  should  be  placed  in  the  fender. 
The  air  of  the  nursery  must  not  be  contaminated  by  dirty 
linen.  The  child's  clothes  must  be  frequently  changed, 
and  soiled  bibs  and  napkins  must  be  removed  from  the 
room  without  unnecessary  delay. 

Attention  must  next  be  directed  to  the  proper  feeding  of 
the  child.  In  cases  where  the  vomiting  has  followed  pre- 
mature weaning,  the  gastric  derangement  is  evidently  due 
to  the  change  of  diet.  Inquiry  should,  therefore,  at  once 
be  made  into  the  kind  of  food  which  has  been  substituted 
for  the  mother's  milk,  and  it  will  usually  be  found  that 
farinaceous  matters  have  been  given  largely  in  excess  of 
the  child's  requirements  or  powers  of  digestion.  In  these 
cases  the  infant's  food  should  be  limited  to  peptonised  cow's 
milk  (see  p.  46),  or  to  equal  parts  of  new  milk  and  barley- 
water.  The  quantity  allowed  must  be  small  at  the  first, 
but  it  can  be  gradually  increased  as  the  condition  of  the 
patient  improves. 


112 


CHRONIC  VOMITING 


If  the  case  be  not  a  severe  one,  and  no  fermenting 
process  be  going  on  in  the  stomach,  such  a  change  of  diet, 
combined  with  other  measures  to  be  afterwards  described, 
will  usually  succeed  in  restoring  the  digestive  organs  to  a 
healthy  condition.  But  when  there  is  a  sour  smell  from 
the  breath  or  body  of  the  child  such  treatment  will  be  of 
little  service.  The  sour  smell  is  the  result  of  fermentation 
of  food,  and  denotes  an  intensely  acid  condition  of  the 
stomach.  In  such  a  case  it  is  indispensable  to  improve- 
ment that  all  fermentable  matters  be  excluded  from  the 
diet.  Even  cow's  milk  itself,  however  diluted  and  alka- 
linised,  can  seldom  be  borne,  as  it  usually  is  vomited  sour 
and  curdled  immediately  after  being  swallowed.  Still, 
woman's  milk  is  sometimes  well  digested,  and  if  the 
infant  be  young,  a  return  to  the  breast  may  be  followed 
by  a  rapid  arrest  of  the  vomiting — the  stomach,  which 
had  rejected  all  other  food,  at  once  recognising  the  change 
of  diet.  Suckling  must,  however,  be  conducted  with 
very  great  care.  In  all  cases  the  child  should  take  the 
breast  at  regular  intervals,  and  should  not  be  allowed  to 
suck  too  long  at  one  time,  the  amount  of  nourishment 
he  is  permitted  to  swallow  being  regulated  on  each  occa- 
sion by  the  degree  of  irritability  of  the  stomach  and  by 
the  result  which  has  followed  the  previous  meal.  If  this 
has  been  rejected,  the  quantity  allowed  to  be  drawn  at 
the  next  suckling  must  be  diminished.  When  infants  are 
very  much  reduced  by  constant  vomiting  the  mere  act  of 
suckling  appears  often  to  excite  retching.  In  such  cases 
the  nurse's  milk  can  be  given  with  a  teaspoon. 

When  a  return  to  the  breast  is  impracticable,  or  is  not 
followed  by  the  expected  improvement — and,  indeed,  in 
many  cases  human  milk  seems  to  agree  as  little  as  the  milk 
of  the  cow— the  diet  should  consist  of  whey  with  cream,* 

*  Fresh  cream,  one  tablespoonful;  whey,  two  tablespoonfuls;  water, 
two  tablespoonfuls.  If  the  cream  obtainable  cannot  be  depended 
upon,  a  good  substitute  is  the  cremor  hordeatus  of  Loeflund. 


DIET 


113 


or  of  equal  parts  of  weak  veal  broth  ^  and  thin  barley- 
water.  In  all  cases  of  severe  and  obstinate  vomiting 
a  stoppage  of  the  ordinary  food  and  a  resort  to  one  of 
these  mixtures,  as  a  substitute  for  the  milk  diet,  will 
almost  certainly  be  followed  by  immediate  relief.  They 
should  be  given  cold;  and,  if  the  vomiting  be  severe,  a 
teaspoonful  only  should  be  allowed  at  one  time.  This 
may  be  repeated  at  intervals  of  ten  minutes.  It  is  only 
after  the  vomiting  has  been  arrested  that  the  child  can  be 
allowed  to  suck  the  food  from  a  feeding-bottle.  If  a 
couple  of  days  have  passed  by  without  any  return  of  the 
sickness,  a  little  milk  may  be  added  to  the  diet.  This 
must  be  given  at  first  with  caution,  and  must  be  pepto- 
nised  or  diluted  with  an  equal  proportion  of  barley-water, 
and  be  aromatised  by  the  addition  of  one  or  two  teaspoon- 
fuls  of  cinnamon  or  car ra way  water.  The  kind  of  milk 
which  agrees  best  in  these  cases  is  that  before  referred  to 
(see  p.  45),  under  the  name  of  strippings."  It  is  rich 
in  cream,  but  comparatively  poor  in  curd,  and  is  therefore 
much  more  digestible  than  the  ordinary  cow's  milk.  If 
this  agrees,  the  quantity  can  be  increased,  and  in  the  course 
of  a  few  days,  by  gradual  steps,  the  child  may  return  to  the 
ordinary  diet  of  health. 

If  the  infant  be  much  weakened,  either  by  the  length 
of  his  illness  or  the  violence  of  the  attack,  white  wine 
whey  "t  should  be  at  once  resorted  to.  The  whey  must 
be  given  perfectly  cold,  and  at  first  in  small  quantities. 
If  the  vomiting  be  frequent,  no  more  than  one  tea-spoon- 

*  The  veal  broth  should  be  of  the  strength  of  half  a  pound  of  veal 
to  the  pint  of  broth. 

t  To  make  "white  wine  whey:" — Put  a  breakfast-cupful  of  new 
milk  into  a  saucepan  on  the  fire.  When  it  boils  add  a  wineglassful  of 
sound  sherry ;  then  boil  again  for  a  couple  of  minutes  and  strain  off 
the  curd.  Afterwards  replace  in  saucepan  and  simmer,  skimming  off 
the  curd  as  it  rises  until  the  whey  is  clear.  The  whey  may  be  sweetened 
with  white  sugar.  The  proportion  of  milk  used  may  be  varied 
according  to  the  strength  of  stimulant  required. 

8 


114 


CHRONIC  VOMITING 


ful  can  be  allowed  at  one  time.  This  method  of  feeding 
almost  always  agrees  well,  and  the  vomiting  ceases  yerj 
quickly.  As  the  irritability  of  the  stomach  subsides  the 
child  may  be  allowed  to  take  more  and  more  of  the  whey, 
and  after  a  few  days  may  suck  it  from  his  feeding  bottle 
like  an  ordinary  food.  In  this  way  the  infant  will  take 
large  quantities  of  stimulant  with  very  great  advantage. 
When  twenty-four  hours  have  passed  by  without  any 
return  of  the  vomiting,  a  tablespoonful  of  fresh  cream 
may  be  shaken  up  with  the  bottleful  of  whey.  If  this  be 
well  digested,  a  return  may  be  made  to  the  ordinary  diet 
by  cautious  steps,  as  already  described. 

Infants  at  the  breast  sometimes  become  the  subjects  of 
a  chronic  gastric  catarrh,  so  that  the  milk,  immediately  it 
is  swallowed,  is  ejected  sour  and  curdled;  and  if  the 
vomiting  continue,  as  it  is  apt  to  do  unless  proper  mea- 
sures be  taken  to  arrest  it,  the  nutrition  of  the  child  may 
be  seriously  impaired.  If  this  derangement  occur  in  a 
very  young  infant  it  is  often  wrongly  concluded  that  the 
breast  milk  is  unsuited  to  the  baby,  and  he  is  ordered  to 
be  weaned.  Such  a  step  is,  however,  seldom  if  ever  neces- 
sary. In  mild  cases  the  administration  of  an  alkali  with  a 
stomachic  such  as  nux  vomica  will  often  arrest  vomiting, 
without  any  change  in  the  diet  being  required. 

In  very  severe  cases  it  will  be  prudent  to  forbid  the 
breast  for  four-and-twenty  hours,  or  even  a  little  longer, 
until  the  vomiting  ceases,  but  suckling  may  be  afterwards 
resumed  without  danger.  In  the  interval  the  child  can  be 
fed  with  whey  and  barley-water,*  mixed  in  equal  propor- 
tions, or  with  the  whey  and  cream,  as  recommended  above. 

*  Barley-water  is  very  useful  in  all  these  cases,  for  it  is  not  only 
perfectly  innocent,  as  a  diet,  but  it  supplies  the  necessary  consistence 
to  the  food.  A  child  will  often  refuse  a  liquid  if  it  be  made  too  thin. 
A  food  to  be  taken  readily  by  babies  must  possess  a  suitable  consist- 
ence. The  barley-water  must  be  made  every  six  hours,  and  kept  in  a 
cool  place  outside  the  sick  room. 


ILLUSTRATIVE  CASE 


115 


The  following  is  an  illustration  of  this  class  of  cases : — 
A.  B.,  a  fine  child,  aged  eight  weeks,  was  stated  to  have 
been  persistently  sick  after  food  ever  since  its  birth.  He 
had  been  suckled  for  the  first  seven  weeks,  but  had  in- 
variably vomited  the  milk  shortly  after  taking  the  breast. 
A  week  before  the  child  came  under  my  notice  he  had 
been  weaned,  and  fed  on  condensed  milk,  diluted  in  the 
proportion  of  a  teaspoonful  to  half  a  tumbler  of  water. 
This,  however,  he  vomited,  as  he  had  done  the  breast 
milk.  He  was  stated  to  smell  sour  occasionally,  and  when 
he  vomited  the  ejected  matters  were  discharged  with  con- 
siderable force,  but  without  any  retching.  The  bowels 
were  loose,  and  the  motions  consisted  principally  of  un- 
digested milk.  The  child  looked  pretty  well,  but  had  a 
slight  yellowish  tint  of  the  skin.   He  was  losing  flesh  fast. 

In  this  case  the  cause  of  the  indigestion  was  evidently 
catarrh  of  the  stomach,  which  dated  from  the  time  of 
birth.  It  was  explained  to  the  mother  that  her  milk  was 
not  unsuited  to  the  child,  but  that  it  disagreed  temporarily, 
as  did  all  other  food,  on  account  of  the  condition  of  the 
digestive  organs.  She  was  recommended  to  begin  nursing 
again  immediately;  but,  as  her  milk  had  partially  dis- 
appeared, the  breast  was  limited  to  two  meals  a  day,  and 
a  supplementary  diet  composed  of  one  teaspoonful  of 
Mellin's  food  for  infants,  dissolved  in  one  part  of  "  strip- 
pings  "  and  two  of  water,  was  ordered,  every  two  hours. 
At  the  same  time  one  quarter  of  a  drop  of  the  tincture  of 
nux  vomica  was  given  with  a  few  grains  of  carbonate  of 
soda,  three  times  a  day,  in  cinnamon  water.  Under  this 
treatment  the  vomiting  soon  ceased,  the  gastric  derange- 
ment quickly  subsided,  and,  as  the  secretion  of  breast 
milk  returned  in  considerable  quantity,  the  child  after  a 
short  time  required  little  food  in  addition  to  that  furnished 
by  his  mother.  In  this  instance  the  derangement  was 
easily  overcome :  but  sometimes  the  vomiting  is  not  so 
readily  arrested.    If  no  milk  could  have  been  borne,  the 


116 


CHRONIC  VOMITING 


Mellin's  food  might  have  been  dissolved  in  barley-water, 
or  in  equal  parts  of  that  and  fresh  whej. 

In  all  cases,  then,  of  obstinate  vomiting  from  a  chronic 
gastric  catarrh  the  question  of  diet  is  determined  upon  the 
simple  principle  of  giving  the  digestive  organs  as  much 
rest  as  possible.  Food  of  the  simplest  character  is  given 
in  small  quantities,  and  if  any  fermentative  process  is 
going  on  in  the  stomach,  it  is  at  once  arrested  by  stopping 
the  supply  of  fermentable  material. 

The  vomiting  which  comes  from  monotony  of  diet  is  at 
once  cured  by  giving  more  variety  in  the  food.  It  is  best 
to  order  three  kinds  of  food  to  be  used  in  rotation  during 
the  day  and  a  desiccated  milk  food  for  the  night,  if 
required.  Each  meal  must  be  prepared  separately  as  it  is 
wanted  (see  Diet  18,  p.  346). 

With  regard  to  the  medicines  to  be  employed : — If  the 
child  is  seen  early  before  the  strength  is  much  reduced, 
and  we  notice  a  sour  smell  from  the  breath  with  a  thickly 
furred  tongue,  an  emetic  should  be  at  once  administered. 
A  teaspoonful  of  ipecacuanha  wine  is  the  best  form  in 
which  this  can  be  given. 

Afterwards,  when  the  stomach  has  been  emptied  of  the 
acrid  secretions  and  mucus,  measures  must  be  taken  to 
quiet  the  gastric  irritability  and  prevent  any  further 
formation  of  acid.  By  far  the  most  valuable  sedative  in 
these  cases  is  arsenic  given  in  small  doses. 

For  a  child  of  three  months  old  a  quarter  of  a  drop  of 
Fowler's  solution  of  arsenic  may  be  given  three  times  a 
day,  with  two  grains  of  bicarbonate  of  soda  in  a  teaspoon- 
ful of  aromatic  water.  At  the  same  time  the  bowels,  if 
confined,  should  be  relieved  by  an  enema  of  barley-water, 
containing  half  an  ounce  of  castor  oil,  and  they  may  be 
kept  in  regular  action  by  one  or  two  drops  of  a  solution  of 
podophyllin  in  alcohol  (a  grain  to  the  drachm),  or  by 
suppositories  of  Castile  soap  placed  in  the  rectum. 

In  cases  where  arsenic  does  not  succeed,  cocain,  one- 


STIMULANTS 


117 


eighth  to  one-fifth  of  a  grain,  may  be  tried  dissolved  in  a 
teaspoonful  of  water,  or  one- sixth  of  a  grain  of  calomel 
may  be  laid  on  the  tongue  every  four  hours,  or  one- sixth 
of  a  drop  of  tincture  of  nux  vomica  may  be  given  with  an 
alkali.  Still,  the  actual  drug  to  be  employed  is  quite  a 
secondary  consideration.  In  bad  cases  our  trust  should 
be  placed,  not  in  the  pharmacopoeia,  but  in  energetic 
measures  for  stopping  the  fermenting  process  and  assist- 
ing the  escape  of  acid  from  the  system.  The  obstinate 
vomiting  is  most  surely  checked  by  giving  the  stomach  as 
much  rest  as  is  consistent  with  supporting  nutrition.  If 
the  diet  has  been  regulated  as  described,  and  if  care  has 
been  taken  to  keep  the  child  warm  and  ensure  a  proper 
relief  from  the  bowels,  the  patient  will,  in  all  probability, 
recover,  whatever  be  the  drug  made  use  of. 

When  the  child  is  much  prostrated,  as  shown  by  the 
depression  of  the  fontanelle,  stimulants  are  always  in- 
dicated. The  white  wine  whey  is  here  of  great  service, 
and  if  the  infant  be  young  should  be  always  resorted  to. 
For  older  children  pale  brandy  may  be  used,  given  in 
doses  of  fifteen  or  twenty  drops  in  a  teaspoonful  of  the 
food  or  of  plain  water.  When  the  prostration  is  great, 
the  stimulant  may  be  repeated  every  hour,  or  even 
oftener. 

If  the  child  is  at  all  weak,  great  caution  must  be  exer- 
cised in  the  use  of  emetics.  An  emetic  is  only  required 
when  there  is  reason  to  suspect  the  presence  of  acrid 
secretions  in  the  stomach.  If,  however,  the  tongue  is 
clean,  and  there  is  no  sour  smell  from  the  breath,  an 
emetic  is  no  longer  indicated,  and  its  employment  would 
only  increase  the  prostration.  Vomiting  is  sometimes 
kept  up  by  debility  of  the  stomach,  and  this  would  be 
only  increased  by  the  exhibition  of  nauseating  remedies. 
When  the  prostration,  as  shown  by  the  condition  of  the 
fontanelle,  is  great,  caution  in  the  use  of  emetics  is 
especially  needful,  as  fatal  syncope  might  follow  their 


118 


CHRONIC  VOMITING 


employment;  and  if  the  fontanelle  is  deeply  depressed, 
they  should  on  no  account  be  made  use  of. 

When  we  are  called  to  a  child  who  presents  the  sym- 
ptoms described  as  spurious  hydrocephalus,  or  to  one  who 
has  been  reduced  by  a  long  continuance  of  this  derange- 
ment to  a  dangerous  degree  of  prostration,  our  first  care 
should  be  to  endeavour  to  restore  the  circulation  to  the 
extremities  by  placing  the  feet  as  high  as  the  knees  in 
hot  mustard  and  water.  This  is  best  done  as  the  child 
lies  on  a  pillow  placed  on  the  nurse's  lap.  If  the  weak- 
ness be  extreme,  the  whole  body  may  be  immersed  for 
three  or  four  minutes  in  a  mustard  bath  as  high  as  the 
neck.  On  being  removed  from  the  bath  the  infant  should 
be  quickly  dried  and  his  limbs  and  belly  thickly  swathed 
in  cotton  wool.  When  returned  to  his  cot  hot  bottles 
should  be  laid  by  his  sides  and  at  his  feet  and  the  most 
perfect  quiet  must  be  enforced.  A  napkin  must  be  placed 
under  the  chin  to  receive  all  matters  ejected  from  the 
stomach ;  and  when  moistened,  the  cloth  must  be  imme- 
diately removed  and  a  clean  one  supplied  in  its  place.  At 
the  same  time  the  food  should  be  limited  strictly  to  white 
wine  whey,  or  to  barley-water  mixed  with  an  equal  pro- 
portion of  weak  veal  broth,  given  cold  with  a  teaspoon. 
If  the  latter  be  used,  five  drops  of  pale  brandy  may  be 
added  to  the  spoonful  of  food  as  often  as  seems  desirable. 
This  state  of  serious  prostration  should  excite  the  gravest 
apprehensions,  for  it  is  rarely  recovered  from.  Mere  weak- 
ness, however,  apart  from  actual  collapse,  is  no  bar  to  re- 
covery. With  proper  measures  success  can  often  be  attained 
even  in  the  very  worst  cases  of  this  derangement,  but  in 
young  babies  especial  care  must  be  taken  to  promote  the 
circulation  and  encourage  the  free  action  of  the  skin. 
While  the  feet  remain  cold  no  treatment  is  likely  to 
succeed. 

After  the  vomiting  has  ceased  and  the  more  urgent 
symptoms  have  been  overcome,  iron  wine  may  be  given 


TREATMENT 


119 


with  a  quarter  or  half  a  drop  of  tincture  of  nux  vomica  to 
the  dose;  and  as  the  child  improves,  he  must  be  taken 
out  of  doors  whenever  the  weather  permits,  for  a  free 
supply  of  fresh  air  is  a  most  important  agent  in  the 
treatment  of  this  as  of  all  the  other  chronic  diseases  of 
children. 


CHAPTER  IV 


RICKETS 

RICKETS,  although  one  of  the  most  preventable  of 
children's  diseases,  is  yet  one  of  the  most  common. 
It  begins  insiduously,  presenting  at  first  merely  the  ordi- 
nary symptoms  of  defective  assimilation,  and  attention  is 
often  not  attracted  to  it  until  the  characteristic  changes 
occur  in  the  bones  which  place  the  existence  of  the  com- 
plaint beyond  a  doubt. 

Many  of  the  symptoms  described  under  the  head  of 
simple  atrophy  constitute  a  preliminary  stage  of  rickets. 
They  are  not,  as  has  been  said,  characteristics  of  this 
special  disorder,  but  merely  mark  the  process  of  gradual 
reduction  of  strength,  and  of  interference  with  the  assi- 
milative functions,  which  must  take  place  to  a  certain 
degree  before  the  disease  can  be  established.  This  pre- 
liminary stage  is  not,  however,  always  present.  Rickets  is 
the  result  of  mal-nutrition ;  any  disease,  therefore,  which 
seriously  interferes  with  the  assimilative  power,  and  causes 
sufficient  impairment  of  the  general  strength,  may  be 
followed  directly  by  the  disorder  under  consideration, 
without  any  intervening  stage.  Reduce  the  strength  to  a 
given  point,  and  rickets  begins.  Prolong  this  state  of 
debility  sufficiently,  and  the  characteristic  changes  re- 
sulting from  the  disease  manifest  themselves.  Any  cause, 
therefore,  which  will  reduce  the  strength  to  this  point  Jays 
the  foundation  of  rickets. 

Symptoms. — The  beginning  of  the  disease  is  indicated 
by  the  occurrence  of  two  very  special  symptoms : — 


EARLY  SYMPTOMS 


121 


One  of  these  is  a  curiously  profuse  sweating  about  the 
head,  neck,  and  upper  part  of  the  chest.  The  perspiration 
is  extreme :  it  will  be  seen  standing  in  large  drops  upon 
the  forehead,  and  often  runs  down  the  face.  There  is 
unusual  moisture  of  the  parts  both  day  and  night ;  but  if 
the  child  falls  asleep,  the  quantity  is  instantly  increased, 
and  at  night  is  sufficient  to  make  the  pillow  wet.  When 
awake,  the  slightest  exertion  or  elevation  of  the  tempera- 
ture excites  it  at  once.  At  the  same  time,  the  superficial 
veins  of  the  forehead  are  large  and  full,  the  jugular  veins 
are  distended,  and  the  carotid  arteries  may  sometimes  be 
felt  strongly  pulsating.  The  irritation  excited  by  this 
constant  perspiration  will  often  give  rise  to  a  crop  of 
miliaria  about  the  temples,  the  upper  part  of  the  forehead 
close  to  the  roots  of  the  hair,  and  at  the  back  of  the  neck. 
While  the  head  and  neck  are  thus  bathed  in  perspiration 
the  abdomen  and  lower  limbs  are  merely  moist,  sometimes 
quite  dry. 

Another  characteristic  symptom  is  the  dislike  of  the 
child  to  warm  coverings  at  night.  In  the  coldest  weather 
he  will  kick  off  the  bedclothes,  or  throw  his  naked  legs 
outside  the  counterpane.  The  mother  often  notices  this 
as  one  of  the  earliest  symptoms,  and  will  say  that  she  has 
been  obliged  to  wrap  her  child  up  in  flannel  to  prevent 
his  catching  cold,  as  he  will  not  remain  covered  by  the 
bedclothes. 

These  two  symptoms  occur  early  and  precede  any  sign 
of  deformity  of  bone.  In  some  children  the  beginning  of 
morbid  change  in  the  osseous  structures  is  indicated  by 
tenderness ;  but  in  an  uncomplicated  case  of  rickets  tender- 
ness is  never  a  marked  symptom.  It  is  true  that  when 
the  disease  is  pronounced  the  patient  is  often  unwilling  to 
be  danced  about;  but  this  disinclination  to  play  is  not 
necessarily  the  consequence  of  tenderness  ;  at  any  rate  it  is 
seen  in  children  who  show  no  sign  of  distress  at  being 
handled.    The  dislike  of  violent  movement  is  apparently 


122 


RICKETS 


due  to  the  hurry  of  breathing  it  induces,  for  when  their 
ribs  are  softened  an  increased  demand  for  air  is  difficult  to 
satisfy.  Marked  tenderness  to  the  touch  in  rickets  is 
usually  a  sign  that  the  case  is  becoming  comj)licated  with 
scurvy. 

The  special  symptoms  are  accompanied  by  all  the 
other  phenomena  which  preceded  the  beginning  of  the 
disease.  The  bowels  remain  confined,  or  are  more  or  less 
capricious,  a  day  or  two  of  relaxation  being  followed  by 
an  equal  period  of  constipation.  More  often,  however, 
there  are  three  or  four  evacuations  in  the  course  of  the 
twenty-four  hours,  accompanied  by  considerable  straining- 
The  stools  consist  of  whitish,  curdy-looking  matter,  mixed 
with  mucus,  and  are  extremely  offensive.  The  food  taken 
seems  to  pass  almost  unchanged  through  the  alimentary 
canal,  being,  no  doubt,  forced  too  rapidly  along  from 
abnormal  exaltation  of  the  peristaltic  action  of  the  bowels, 
so  that  sufficient  time  is  not  allowed  for  digestion.  A 
certain  amount  of  abdominal  discomfort  appears  to  be 
common  in  these  cases,  for  the  child  may  often  be  noticed 
to  turn  round  in  his  cot  on  to  his  face,  and  will  sometimes 
fall  asleep  resting  upon  his  arms  and  knees,  with  his  head 
buried  in  the  pillow.  The  urine  becomes  more  abundant 
and  deposits  a  calcareous  sediment,  or  abounds  in  phos- 
phates. There  is  usually  some  thirst ;  but  the  appetite  is 
often  voracious,  so  that  the  child  very  shortly  after  a 
meal  will  show  a  disposition  to  eat  again.  This  is  what 
we  constantly  meet  with  in  cases  of  dyspepsia  in  the 
adult,  where  the  peristaltic  action  of  the  intestines  is 
unnaturally  brisk.  The  child  soon  loses  his  power  of 
walking,  and  sits,  or  lies  about.  He  becomes  dull  and 
languid,  and  neglects  his  playthings.  There  is  usually 
some  emaciation ;  but  if  the  symptoms  are  not  severe  at 
the  first,  he  may  be  plump  in  appearance,  although  his 
flesh  feels  soft  and  flabby.    In  the  daytime  he  is  drowsy, 


DEFORMITIES  OF  BONE 


123 


but  at  night  is  restless,  turning  his  head  uneasily  from 
side  to  side  on  the  pillow. 

The  symptoms  proper  to  rickets  very  seldom  appear 
before  the  fourth  month,  and  not  commonly  before  the 
seventh  or  eighth.  From  my  own  experience  I  should 
say  that  the  disease  manifests  itself  most  frequently 
between  the  seventh  and  eighteenth  months,  less  fre- 
quently between  the  eighteenth  month  and  the  end  of  the 
second  year,  and  rarely  after  the  end  of  the  second  year. 
Still,  we  may  find  it  beginning  at  a  later  period ;  and 
Sir  William  Jenner  mentions  the  case  of  a  girl,  aged  nine 
years,  who  had  then  only  just  begun  to  suffer. 

At  the  time  when  general  tenderness  is  first  complained 
of  the  deformities  of  the  bones  usually  attract  notice. 
In  the  first  place,  the  articular  ends  of  the  bones  enlarge 
at  the  point  of  junction  of  the  bone  with  its  epiphysis. 
Both  ends  may  suffer,  but  the  change  is  necessarily  more 
evident  in  the  extremity  which  is  superficial  than  in  that 
which  is  more  deeply  placed.  The  ribs  at  their  sternal 
ends  are  usually  the  first  to  be  affected ;  next  the  bones  at 
the  wrists ;  and,  as  a  rule,  the  enlargement  is  greater  in 
the  bones  of  the  upper  limbs  than  in  those  of  the  lower. 
The  flat  bones — the  bones  of  the  skull,  the  scapula,  and 
the  pelvis — become  thickened ;  and  all  the  bones  become 
softened.  It  is  this  softening  of  the  bones  which,  owing 
to  mechanical  causes,  leads  to  the  distortions  so  charac- 
teristic of  the  disease. 

In  a  well-marked  case  of  rickets  we  find  all  these 
changes  ;  but  very  commonly  many  of  them  are  absent. 
Even  when  present  they  do  not  always  occur  to  an  equal 
degree ;  in  some  cases  the  softening  of  the  bones  is  more 
marked  than  their  enlargement ;  in  others,  the  enlarge- 
ment is  out  of  proportion  to  the  softening.  M.  Gruerin 
has  stated — he  has  even  laid  it  down  as  an  absolute  rule 
— that  the  deformities  of  the  bones  begin  from  below  up- 
wards, that  the  tibise  become  affected  before  the  .thigh 


124 


RICKETS 


bones,  the  thigh  bones  before  the  pelvis,  and  so  on  to  the 
arms  and  head.  This,  however,  is  not  correct.  In  some 
cases  we  certainly  find  the  legs  and  thighs  bowed  earlier 
than  the  other  parts,  but  it  is  in  children  who  have  walked, 
or  can  still  walk ;  and  in  them  the  weight  of  the  body 
determines  the  deformities  of  the  lower  limbs  before  the 
pressure  upon  the  other  bones  has  been  sufficient  to  make 
them  crooked.  Besides,  if  a  very  heavy  child  be  put  on 
his  legs  at  too  early  an  age  the  tibiae  may  bend  a  little, 
although  there  is  no  reason  to  suspect  the  child  of  being 
the  subject  of  rickets. 

The  changes  produced  by  the  disease  in  the  various 
bones  are  as  follows  : 

Bones  of  the  head  and  face. — The  skull  is  larger  than  it 
ought  to  be,  and  is  of  a  peculiar  shape.  Its  antero- 
posterior diameter  is  increased ;  the  f  ontanelle  remains 
open — often  widely  open — long  after  the  end  of  the  second 
year,  the  ordinary  period  of  its  closing;  the  thickening 
of  the  bones  is  most  marked  at  the  centres  of  the  parietal 
bones,  the  bosses  of  the  temporal  bones,  and  at  the  edges 
of  the  bones  outside  the  sutures,  so  that  the  situation  of 
the  sutures  is  indicated  by  deep  furrows;  the  vertex  is 
flattened,  and  the  sutures  are  expanded  or  remain  open. 
The  forehead  is  high,  square,  and  projecting,  and  is  out 
of  proportion  to  the  face.  This  disproportion  is  exagge- 
rated by  the  arrest  of  growth  of  the  bones  of  the  face, 
particularly  of  the  bones  of  the  upper  jaw  and  the  malar 
bones ;  therefore,  while  the  forehead  is  larger,  the  face  is 
smaller  than  natural.  The  projection  of  the  forehead  is 
due  partly  to  thickening  of  the  frontal  bone,  partly  to 
expansion  of  the  frontal  and  ethmoidal  sinuses,  and  partly 
to  enlargement  of  the  brain.  The  shape  of  the  lower  jaw 
is  peculiar.  The  normal  curve  has  disappeared.  Anteriorly 
the  bone  is  flattened,  but  laterally,  at  the  situation  of 
the  eye-teeth,  it  bends  abruptly  backwards  at  a  sharp 
angle.    This  change  is  due,  according  to  Pleischmann, 


CHANGES  IN  CRANIAL  BONES 


125 


to  the  imperfect  growth  of  the  middle  portion  of  the 
jaw. 

A  curious  deformity  of  the  cranial  bones  is  sometimes 
seen  which  closely  resembles  the  "  natiform  "  skull  of  in- 
herited syphilis,  and  is  often  mistaken  for  it.  The  frontal 
and  parietal  eminences  become  greatly  exaggerated,  and 
form  prominent  bosses,  which  surround  the  anterior  fon- 
tanelle  and  constitute  the  "  natiform  "  or  hot  cross-bun  " 
shape  of  the  skull.  The  bosses  do  not  encroach  upon  the 
fontanelle  so  closely  as  in  the  specific  disease,  and  the 
edges  of  the  bones  which  bound  the  fontanelle  can  be  felt 
to  be  thickened  and  not  thinned  as  in  syphilis.  These 
differences  are  sufficiently  distinctive  in  an  ordinary  case ; 
but  sometimes  we  find  a  mixture  of  the  two  forms  owing 
to  rickets  having  become  developed  in  an  infant  the  subject 
of  inherited  syphilis.  In  such  a  case  the  part  which  each 
disease  takes  in  developing  the  osteal  deformity  is  not  easy 
to  determine. 

It  is  important  to  distinguish  between  the  rickety  en- 
largement of  the  skull  and  the  expansion  which  takes  place 
in  hydrocephalus.  In  hydrocephalus  there  is  greater  dis- 
proportion between  the  skull  and  the  face ;  the  enlarge- 
ment is  more  globular  and  regular,  the  antero-posterior 
diameter  not  being  greater  than  the  lateral ;  the  bones  of 
the  skull  do  not  give  to  the  finger  the  sensation  of  being 
thickened ;  the  fontanelle  is  more  open,  and  if  the  accumu- 
lation of  fluid  be  great,  the  bones  at  the  sutures  are  more 
widely  separated ;  the  sutures  themselves  are  not  bounded 
by  a  ridge  of  thickened  bone.  The  fontanelle  in  hydro- 
cephalus is  often,  although  not  always,  elevated ;  in  rickets 
it  is  depressed,  partly  on  account  of  the  debility,  partly  on 
account  of  thickening  of  the  bones  which  forms  its  boun- 
daries. In  rickets  we  find  other  well-marked  symptoms 
showing  the  nature  of  the  complaint.  The  two  diseases 
are,  however,  occasionally  combined.  A  moderate  excess  of 
fluid  in  the  skull  is  not  uncommon  in  rickets.    In  such 


126 


RICKETS 


cases  the  configuration  of  tlie  head  and  body  generally  is 
that  of  rickets,  while  the  fontanelle  is  large  and  elevated, 
and  the  sutures,  if  there  be  much  fluid,  are  open  and 
fluctuating. 

A  curious  condition  of  the  skull,  first  detected  by 
Elsasser,  and  known  as  craniotahes,  may  be  present. 
On  using  gentle  pressure  with  the  tips  of  the  fingers  over 
the  posterior  surface  of  the  head  spots  can  sometimes  be 
detected  where  the  bone  is  thinned.  The  bone  at  these 
spots  is  elastic,  feels  like  cartridge  paper,  and  presents  a 
concavity  or  depression,  which  varies  in  size  according  to 
the  extent  of  the  thinning.  The  usual  size  of  these  de- 
pressions varies  from  a  linseed  to  a  bean ;  but  one  whose 
size  does  not  exceed  a  line  in  diameter  can  be  detected  by 
the  practised  finger. 

These  local  losses  of  substance  are  confined  to  the 
occipital  bone,  of  which  any  part  may  be  affected  except 
the  protuberances.  The  frontal  and  parietal  bones  are, 
on  the  contrary,  greatly  thickened,  often  to  double  their 
natural  depth. 

The  progress  of  dentition  is  arrested.  If  the  disease 
make  its  appearance  before  any  of  the  teeth  are  cut,  their 
evolution  may  be  almost  indefinitely  postponed.  If  some 
teeth  have  already  appeared,  the  further  progress  of  den- 
tition is  interrupted.  This  influence  over  the  teeth  is 
peculiar  to  rickets.  In  no  other  disease,  in  which  general 
nutrition  is  affected,  do  we  find  any  interference  with  the 
natural  course  of  dentition.  In  a  child  greatly  wasted  by 
chronic  diarrhoea,  or  improper  food,  the  development  of 
the  teeth  does  not  seem  to  be  hindered  by  causes  which 
exert  so  powerful  an  influence  upon  his  general  health  ; 
and  in  tuberculosis  and  congenital  syphilis,  as  a  rule,  the 
teeth  are  cut  early. 

Often  in  rickets  the  teeth  are  not  only  late  to  appear,  but 
are  cut  very  irregularly.  Sometimes  the  first  tooth  to 
pierce  the  gum  is  a  molar.  Although  cut  late  the  teeth  are 


CURVATURE  OF  SPINE 


127 


cut  with  little  effort.  As  a  rule  a  rickety  child  suffers  from 
dentition  hardly  at  all.  His  teeth,  however,  speedily  become 
black,  decay,  and  drop  early  from  their  sockets.  This  is 
due  to  insufficient  development  of  the  dental  enamel.  It 
is  not  at  all  uncommon  to  see  a  rickety  child  of  eighteen 
months  or  two  years  old  with  very  few  teeth  as  yet  in  his 
head,  and  those  few  black  and  carious. 

In  some  rare  cases,  however,  we  find  dentition  un- 
affected, and  even  particularly  forward,  although  the  other 
symptoms  of  rickets  are  well  marked.  Thus  Herbert  K. 
cut  his  first  tooth  when  five  months  old,  and  at  the  age  of 
one  year  and  nine  months  dentition  was  completed.  He 
could  not  stand  until  his  seventeenth  month,  and  when  a 
year  and  a  half  old  could  not  walk  without  assistance. 
It  was  only  just  before  cutting  his  last  tooth  that  he  was 
able  to  walk  alone.  When  seen,  he  was  aged  two  years 
and  nine  months,  a  pale  and  rather  weakly-looking  boy ; 
wrists  large  ;  tibiae  bowed ;  the  teeth,  however,  were  perfect 
and  particularly  sound. 

The  spine  is  bent ;  and  the  curvature  is  in  proportion 
to  the  degree  of  muscular  weakness,  so  that  if  there  be 
much  deformity  it  is  a  sign  that  this  weakness  is  great. 
The  direction  of  the  curve  varies  according  to  whether 
the  child  can  or  cannot  walk.  If  the  child  cannot  walk, 
the  cervical  anterior  curve  is  increased,  and  there  is  a  pos- 
terior curve  reaching  from  the  first  dorsal  to  the  last 
lumbar  vertebrae.  This  is  an  exaggeration  of  the  ordinary 
curve  which  exists  when  a  child  sits  unsupported  on  the 
arm  of  his  nurse.  If  the  muscular  debility  is  very  great 
the  curvature  may  be  so  pronounced  as  to  be  mistaken 
for  angular  curvature.  It  is,  however,  readily  distin- 
guished by  holding  the  child  up,  supporting  him  with  the 
hands  under  the  arms  :  the  weight  of  the  body  will  then 
usually  straighten  the  spine  at  once,  particularly  if  gentle 
pressure  is  at  the  same  time  made  on  the  projecting 
part. 


128 


RICKETS 


If  the  child  is  able  to  walk  the  dorsal  spine  is  curved 
backwards,  the  lumbar  forwards. 

As  a  consequence  of  the  cervical  curve,  and  the  accom- 
panying weakness  of  the  muscles,  the  head  is  no  longer 
efficiently  supported;  it,  therefore  falls  back,  and  the 
peculiarity  of  the  attitude  thus  assumed  as  the  child  sits 
up  in  his  cot  is  very  characteristic  of  the  disease. 

Lateral  curvatures  are  occasionally  seen,  but  they  are 
far  less  common  than  the  antero-posterior.  Their  direc- 
tion is  determined  by  the  position  assumed  by  the  child. 
If  he  is  carried  constantly  on  the  left  arm  there  is  lateral 
curvature,  with  convexity  to  the  left ;  if  on  the  right  arm, 
the  convexity  is  to  the  right. 

The  thorax  is  curiously  deformed.  Flattened  behind, 
projecting  sharply  in  front,  it  presents  an  appearance 
which  Grlisson  compares  to  the  prow  of  a  ship,  and  which 
forms  the  condition  commonly  known  as  pigeon  breasted." 
The  ribs,  as  they  leave  the  spine,  are  directed  at  first 
almost  horizontally  outwards,  then  bend  sharply  at  an 
acute  angle  at  the  junction  of  the  dorsal  and  lateral 
regions,  and  from  that  point  j)ass  forwards  and  inwards 
to  unite  with  their  cartilages.  The  cartilages  curve  out- 
wards before  turning  in  to  their  articulations  with  the 
sternum,  so  that  the  breast-bone  is  forced  forwards,  and 
the  antero-posterior  diameter  of  the  chest  is  unnaturally 
increased.  The  lateral  diameter  is  greatest  opposite  the 
acute  angle  formed  by  the  ribs  ;  least,  at  the  points  of 
junction  of  the  ribs  with  their  cartilages.  This  curving 
inwards  of  the  ribs,  and  outwards  of  the  cartilages,  forms 
a  groove  on  the  antero-lateral  face  of  the  chest,  which 
reaches  from  the  ninth  or  tenth  rib  below,  to  the  third, 
second,  or  even  first  rib  above ;  and  the  groove  is  deepest 
just  outside  the  nodules  formed  by  the  enlarged  ends  of 
the  ribs.  The  groove  varies  on  the  two  sides  in  length 
and  in  depth,  for  the  liver  and  the  heart  support  to  a 
certain  extent  the  ribs  under  which  they  lie.    Thus  the 


DEFORMITY  OF  CHEST 


129 


groove  reaches  downwards  to  a  less  distance  on  the  right 
side  than  on  the  left,  on  account  of  the  liver  ;  and  at  the 
level  of  the  fourth  and  fifth  ribs  it  is  shallower  on  the  left 
side  than  the  right,  on  account  of  the  heart.  The  enlarge- 
ment of  the  ends  of  the  ribs  gives  a  peculiar  appearance 
to  the  surface  of  the  chest;  a  line  of  nodules  is  seen, 
on  the  inner  side  of  the  groove,  looking  like  a  row  of 
large  beads  under  the  skin.  Below  the  sixth  rib  the 
chest  widens,  as  the  walls  are  forced  outwards  by  the 
underlying  liver,  stomach,  and  spleen. 

If  we  strip  a  rickety  child  and  watch  his  breathing,  we 
see  that  in  inspiration  there  is  sinking  in  of  the  chest 
walls.  The  lateral  depressions  deepen ;  the  sternum 
moves  forwards ;  the  abdomen  expands ;  and  a  deep 
horizontal  groove  furrows  the  surface,  dividing  the  chest 
from  the  belly,  and  marking  the  upper  borders  of  the 
abdominal  viscera.  This  recession  of  the  chest  walls 
shows  the  mechanism  by  which  the  deformity  is  produced. 
In  the  healthy  subject  when  the  diaphragm  contracts, 
and  the  ribs  are  elevated  in  the  act  of  inspiration,  air 
rushes  in  through  the  glottis  to  expand  the  lungs,  and  to 
enable  them  to  follow  and  remain  in  contact  with  the 
expanding  chest  walls.  The  atmospheric  pressure  is, 
therefore,  overcome  by  the  power  of  the  osseous  and 
muscular  walls,  aided  by  the  pressure  of  the  inspired  air. 
In  the  rickety  child,  however,  one  of  these  agents  is  com- 
paratively powerless.  The  softened  ribs  can  afford  little 
assistance  to  the  air  within  the  chest  in  resisting  the 
pressure  outside :  they  therefore  sink  in  at  their  least 
supported  parts,  and  produce  the  lateral  furrows  which 
have  been  described,  while  at  the  same  time  the  sternum 
is  carried  forwards  in  proportion  to  the  recession  of  the 
ribs. 

Eokitansky  held  that  chest  deformity  was  due  to  want 
of  power  in  the  inspiratory  muscles.  Sir  W.  Jenner, 
however,  has  shown  that  the  points  of  insertion  of  the 

9 


130 


RICKETS 


muscles  of  respiration  do  not  tally  with  the  point  of  re- 
cession of  the  chest  walls  ;  and  that  the  horizontal  de- 
pression at  the  base  of  the  chest  corresponds,  not  to  the 
points  of  attachment  of  the  diaphragm,  but  to  the  upper 
borders  of  the  liver,  stomach,  and  spleen.  These  organs 
support  the  parietes,  and  prevent  any  sinking  in  under 
the  pressure  of  the  air.  A  similar  cause  produces  an 
apparent  bulging  of  the  prsecordial  region  during  inspira- 
tion, for  the  heart  supports  the  ribs  behind  which  it  lies, 
and  prevents  their  receding  to  the  same  extent  as  the  walls 
around. 

The  influence  of  adenoid  vegetations  in  promoting  chest 
distortion  must  not  be  forgotten.  These  growths  interfere 
greatly  with  the  full  expansion  of  the  lungs ;  and  imper- 
fect pulmonary  inflation  cannot  but  weaken  the  resistance 
of  the  thoracic  contents  to  external  atmospheric  pressure. 
In  most  rickety  children  with  marked  chest  distortion, 
adenoid  growths  will  be  found  on  examination  of  the  naso- 
pharynx. 

The  clavicle  is  distorted.  There  are  two  great  curves ; 
the  principal  one,  forwards  and  rather  upwards,  is  situated 
just  outside  the  points  of  attachment  of  the  sterno- 
mastoid  and  pectoral  muscles.  The  second,  backwards,  is 
about  half  an  inch  from  the  scapular  articulation. 

The  humerus  is  sometimes  curved  just  where  the  deltoid 
muscle  is  inserted. 

The  radius  and  ulna  are  curved  outwards,  and  also 
twisted. 

These  deformities  are  ascribed  by  most  authors  to 
muscular  action,  aided  by  the  weight  of  the  limb.  Sir 
W.  Jenner,  however,  excludes  altogether  the  first  men- 
tioned cause  from  any  share  in  the  production  of  these 
distortions.  They  are  due,  he  says,  to  the  habit  prac- 
tised by  all  rickety  children,  owing  to  their  deficiency  in 
muscular  power,  of  supporting  the  body,  while  sitting, 
upon  the  open  hands  placed  upon  the  bed  or  floor.  The 


THE  PELVIS 


131 


weight  of  the  trunk  is  therefore,  in  a  great  measure, 
thrown  upon  the  arms,  and  we  see  in  consequence  the 
deformities,  of  the  clavicle,  the  humerus,  and  the  bones  of 
the  forearm,  which  have  been  described.  The  curvature 
of  the  humerus  is  also  aided  by  the  weight  of  the  forearm 
and  hand  when  the  limb  is  raised  by  the  action  of  the 
deltoid.  The  weight  of  the  arm  on  the  humeral  end  of 
the  clavicle — the  sternal  end  being  supported  by  its 
muscles  and  ligaments — will  also  assist  in  producing  the 
disfigurement  of  the  collar-bone. 

The  scapula  is  very  much  thickened,  and  is  said  occa- 
sionally to  be  so  deformed  as  to  interfere  with  free  motion 
of  the  shoulder- joint. 

The  pelvis  varies  greatly  in  shape,  but  is  more  often 
triangular  than  oval.  Pressure  may  be  brought  to  bear 
upon  it  in  many  different  directions ;  thus  it  is  pressed 
upon  from  above  by  the  weight  of  the  spine  and  the  con- 
tents of  the  abdomen;  from  below  by  the  heads  of  the 
thigh  bones.  The  exact  direction  in  which  these  com- 
pressing forces  will  act  varies,  firstly,  according  to  the 
position  of  the  child — lying,  sitting,  standing,  or  walking ; 
and  secondly,  according  to  the  age  at  which  the  disease 
comes  on,  and  therefore  according  to  the  degree  of  ossifi- 
cation of  the  bones,  for  the  cartilages  are  less  yielding  than 
the  bones  themselves.  The  distortion  of  the  pelvis  thus 
produced  is  often  very  remarkable.  In  a  child  of  four- 
and-half  years  old,^  in  Avhom  lithotomy  was  performed  by 
Sir  Henry  Thompson,  at  University  College  Hospital,  the 
outlet  of  the  pelvis  was  so  contracted  as  barely  to  allow  a 
stone,  measuring  1^  in.  in  length,  |  in.  breadth,  and  |  in. 
in  thickness,  to  pass  through  in  its  long  axis. 

The  child  died  shortly  after  the  operation  from  perito- 
nitis, and  on  examination  of  the  pelvis  the  brim  was  found 
to  be  exceedingly  contracted.     Its  shape  was  obliquely 

*  An  account  of  this  case  will  be  found  in  the  '  Medical  Times  and 
Gazette'  for  December  5,  18G3. 


132 


RICKETS 


caudate :  the  sacral  promontory  was  distant  i  in.  from  the 
left  pubic  ramus,  |  in.  from  the  pubic  ramus  of  the  right 
side,  and  |  in.  from  the  symphysis  of  the  pubes. 

Besides  the  softening  of  the  bones  there  is,  however, 
another  cause  which  tends  to  keep  the  cavity  of  the  pelvis 
narrow  and  contracted,  as  is  explained  afterwards. 

The  femur  is  curved  forwards  if  the  child  cannot  walk. 
If  he  can  walk  it  is  curved,  forwards  and  outwards,  being 
an  exaggeration  of  the  natural  curve.  Sometimes  the  head 
of  the  femur  is  seen  bent  at  an  acute  or  an  obtuse  angle  to 
the  shaft. 

The  tibia,  before  the  child  walks,  is  curved  outwards, 
and  the  knees  are  then  seen,  as  the  child  is  held  upright, 
to  be  widely  separated  from  one  another.  After  the  child 
walks  the  weight  of  the  body  determines  the  bending.  In 
these  cases  the  distortion  is  seen  principally  at  the  lower 
third,  and  the  curve  is  very  abrupt,  seeming  to  project 
over  the  foot ;  or  the  bend  may  be  outwards,  projecting 
over  the  outer  ankle. 

In  these  cases,  also,  the  deformity  can  be  explained 
otherwise  than  by  the  influence  of  muscular  action.  While 
the  child  sits  in  his  mother's  lap  the  weight  of  the  legs 
and  feet,  pulling  upon  the  lower  end  of  the  femur,  pro- 
duces the  forward  curvature  of  that  bone.  As  the  child 
sits  cross-legged  on  the  floor  or  bed  the  pressure  on  the 
external  malleolus  causes  the  normal  curve  of  the  tibia  to 
be  exaggerated. 

The  lower  limbs  are  not,  however,  deformed  in  every 
case  of  rickets.  If  the  child  be  unable  to  walk  at  the  time 
when  the  changes  in  the  bones  begin,  the  lower  limbs  may 
escape  distortion  altogether.  In  such  cases  the  muscles  are 
excessively  flabby,  and  the  limbs,  feeble  and  small,  look 
too  short  for  the  body;  but  the  bones  themselves  are 
straight.  The  upper  limbs  seldom  share  this  freedom  from 
deformity ;  but,  owing  to  the  child's  habit  of  supporting 
himself,  as  he  sits,  with  his  hands  placed  upon  the  bed  or 


BONE  SOFTENING 


133 


floor  before  him,  usually  present  the  characteristic  dis- 
figurements which  have  been  described. 

The  changes  in  the  bones  may  take  place  to  any  degree. 
Some  may  be  more  marked,  others  less,  according  to  the 
severity  of  the  disease,  the  age  of  the  child,  and  the  time 
at  which  treatment  is  commenced.  If  the  premonitory 
symptoms  have  been  very  mild,  tenderness  may  be 
altogether  absent,  and  the  affection  of  the  bones  be 
limited — at  any  rate,  at  first — to  bending  of  the  ribs, 
enlargement  of  the  wrists  and  ankles,  postponement  of 
dentition,  and  abnormal  openness  of  the  fontanelle.  The 
child,  if  able  to  walk,  is  still  pretty  strong  on  his  legs; 
he  is  lively,  often  plump,  and  does  not  appear  to  suffer 
much  from  the  disease  under  which  he  is  labouring.  If 
treatment  be  at  once  had  recourse  to  nutrition  is  restored, 
growth  and  development  begin  again,  and  health  quickly 
returns.  On  the  other  hand,  if  the  general  symptoms 
which  precede  the  attack  have  been  very  severe,  i.  e.ii  the 
debility  resulting  from  the  deficient  nutrition  is  very  great, 
the  tenderness  of  the  bones  is  a  well-marked  symptom,  the 
softening  usually  precedes,  and  is  out  of  proportion  to,  the 
enlargement  of  the  ends  of  the  bones,  and  all  the  distor- 
tions which  have  been  described  are  the  result. 

Again,  the  older  the  child  when  rickets  first  appears, 
the  less  likely  is  he  to  be  affected  early  by  softening  of 
the  bones  ;  while,  if  the  child  be  very  young,  the  bones 
usually  soften  very  quickly.  This,  however,  is  perhaps 
merely  a  consequence  of  what  has  just  been  stated,  for 
the  younger  the  child  the  more  likely  is  his  system  to  be 
profoundly  affected  by  malnutrition,  and  therefore  the 
more  severe  will  be  the  consequences  of  that  malnutrition. 

Besides  the  softening  of  the  bones,  and  the  deformities 
which  resiilt  from  it,  there  is  another  effect  of  the  disease 
which  is  not  less  remarkable.  This  effect  is  the  arrest  of 
growth  of  the  bones.  Growth  is  arrested  not  only  while 
the  disease  is  in  progress,  but  even  after  apparent  restora- 


134 


RICKETS 


tion  to  health.  In  a  rickety  skeleton  all  the  bones  are 
found  to  be  stunted  in  growth,  and  this,  combined  with 
the  bending  of  the  lower  limbs,  which  must  necessarily 
detract  from  the  height  of  the  individual,  is  the  cause  of 
the  short  stature  of  persons  who,  when  young,  have  been 
subject  to  this  disease.  The  arrest  of  growth  affects  some 
bones  more  than  others,  being  principally  noticeable  in  the 
bones  of  the  face,  of  the  lower  limbs,  and  of  the  pelvis. 
As  it  affects  the  pelvis  the  want  of  growth  is  very  im- 
portant from  its  influence  upon  child-bearing  in  after  life. 
In  the  child  the  size  of  the  pelvis  and  lower  limbs  is  small 
in  proportion  to  the  rest  of  the  body ;  in  the  adult  female 
it  has  so  increased  as  to  be  relatively  larger  than  the  other 
parts  of  the  bony  framework.  If  then  the  growth  and 
development  of  the  pelvis  are  arrested,  its  brim  and  outlet 
do  not  undergo  the  usual  expansion,  but  remain  small  and 
contracted,  retaining  the  characters  of  the  infantile  pelvis. 
The  obstacle  to  the  passage  of  the  foetal  head,  under  such 
circumstances,  becomes  extreme,  es23ecially  if  conjoined 
with  deformities  produced  by  softened  bone,  and  usually 
requires  craniotomy  or  embryotomy  before  the  child  can 
be  extracted.  This  condition  of  the  pelvis  may  also  inter- 
fere with  operations  upon  the  child,  as  in  the  case  of  litho- 
tomy already  referred  to.  According  to  Mr.  Shaw,  there 
is  a  correspondence  between  the  degree  to  which  the  pelvis 
sulfers  from  this  arrest  of  growth  and  development,  and 
the  degree  to  which  the  lower  limbs  suffer  from  the  same 
causes;  we  can,  therefore,  by  observing  the  amount  of 
stunting  of  the  lower  limbs,  make  some  estimate  of  the 
extent  to  which  the  pelvis  is  likely  to  be  modified  in  size 
and  capacity. 

The  articulations. — As  the  ends  of  the  long  bones  are 
enlarged  the  joints  into  which  these  bones  enter  must 
necessarily  be  enlarged  also.  They  have  therefore  a 
knotted,  bulbous  look,  an  appearance  which  is  aggravated 
by  the  atrophy  of  the  muscles  of  the  limb.    In  addition 


THE  JOINTS 


135 


to  this  the  ligaments  which  hold  the  bones  together  are 
relaxed :  the  joints  are  therefore  loose  and  unsteady,  and 
can  be  moved  freely  in  directions  which  in  a  healthy  state 
would  be  impossible.  This  looseness  and  mobility  of  the 
joints  forms  alone  a  great  impediment  to  walking,  even 
when  the  bones  themselves  are  healthy ;  and  in  fact  the 
relaxation  of  the  ligaments  does  not  always  bear  a  due 
proportion  to  the  osseous  changes.  It  is  often  an  early 
symptom ;  and  we  frequently  see  it  carried  to  a  high 
degree  in  cases  where  the  disease  in  the  bones  is  as  yet 
comparatively  trifling.  In  these  cases,  if  we  hold  the 
child  upright,  so  that  the  weight  of  the  body  rests  upon 
the  feet,  we  see  that  each  lower  limb  forms  an  obtuse 
angle  at  the  knee ;  the  knees  touch ;  the  legs  are  directed 
outwards;  and  the  foot  is  more  or  less  everted,  from 
relaxation  of  the  ligaments  of  the  ankle.  In  children  in 
whom  the  disease  appears  at,  or  after,  the  end  of  the 
second  year,  this  weakness  in  the  joints  is  a  very  prominent 
symptom,  and  is  often  found  where  the  limbs  are  perfectly 
straight  and  well  formed. 

All  the  joints  in  the  body  are  sharers  in  this  ligament- 
ous weakness,  for  it  is  not  confined  to  the  articulations  of 
the  limbs.  The  fibrous  bands  which  connect  the  vertebrae 
with  each  other  and  with  the  sacrum,  the  sacrum  with 
the  pelvis,  are  alike  affected  ;  and  it  is  a  conjunction  of 
all  these  various  lesions,  combined  with  the  softening  of 
the  bones,  and  the  weakness  of  the  muscles,  which  pro- 
duces the  inability  to  walk,  and  the  difficulty  of  holding 
the  body  upright,  which  are  so  characteristic  of  the 
disease. 

The  general  symptoms  continue  while  these  changes  are 
going  on.  There  is  no  fever,  but  perspiration  is  profuse, 
and  the  tenderness  increases  in  proportion  to  the  softening 
of  the  bones.  The  appetite  may  remain  ravenous,  but 
more  often  it  diminishes,  and  the  child  shows  a  disgust 
for  food,  or  only  exhibits  a  craving  for  beer,  and  the  more 


136 


RICKETS 


tasty  articles  of  diet.  Sickness  frequently  occurs  at  tliis 
time,  for  attacks  of  gastric  derangement  often  complicate 
the  disease,  and  aggravate  it.  In  these  cases  there  is 
a  sour  smell  from  the  breath ;  the  vomited  matters  are 
acid;  the  bowels  either  become  constipated,  or  there  is 
diarrhoea,  with  green,  slimy,  offensive  stools,  showing 
the  participation  of  the  intestinal  mucous  tract  in  the 
derangement. 

Emaciation  is  the  rule  in  rickets,  and  if  the  disease  be 
at  all  advanced,  is  invariably  present.  During  the  early 
stage,  as  has  been  said,  a  rickety  child  may  be  plump. 
Infants  crammed  with  large  quantities  of  fat-forming 
material,  and  at  the  same  time  deprived  of  a  sufficiency 
of  fresh  air,  are  apt  to  get  large  and  unwieldy,  although 
they  are  not  the  less  anaemic  and  feeble.  A  want  of  colour 
is  noticed  in  the  face  ;  the  mucous  membranes  are  pallid  ; 
the  muscles  ill-grown ;  the  bones  and  ligaments  weak ; 
and  the  child  lethargic  and  quiet.  After  a  time  the 
digestive  powers  cease  to  be  equal  to  the  burden  imposed 
upon  them ;  a  gastric  catarrh  is  set  up,  and  the  interference 
with  the  nutritive  processes,  thus  established,  soon  induces 
a  rapid  loss  of  flesh.  The  fat  disappears,  and  the  muscles 
get  more  and  more  flabby  and  wasted.  The  loss  of  power 
in  the  muscles  is,  however,  greater  than  can  be  accounted 
for  by  the  wasting ;  and  if  the  disease  be  severe,  the  child 
may  be  incapable  of  supporting  himself  in  the  slightest 
degree. 

The  face  gets  old-looking ;  the  eyes  are  large  and  staring^ 
and  the  general  expression  is  placid,  although  rather 
languid.  The  respiration  is  quick  and  laborious,  and  if 
there  be  much  softening  of  the  ribs,  and  consequent  reces- 
sion of  the  chest  walls,  the  child's  whole  faculties  appear 
to  be  concentrated  upon  the  performance  of  the  respiratory 
act.  Such  a  child  will  give  little  trouble  to  his  attendants  ; 
in  fact,  the  little  creature  has  no  breath  to  spare  for  idle 
lamentations,  and  cannot  aft'ord  to  cry. 


ABDOMINAL  ORGANS 


137 


The  abdomen  is  very  large,  and  often  appears  enor- 
mously distended  when  compared  with  the  narrowed  and 
distorted  chest.  This  enlargement  of  the  belly  is  due  to 
depression  of  the  diaphragm  and  diminished  capacity  of 
the  thorax,  which  force  down  the  liver  and  spleen  below 
the  level  of  the  ribs ;  to  increased  shallowness  of  the 
pelvis ;  to  the  flabby  condition  of  the  abdominal  muscles 
favouring  the  accumulation  of  flatus  generated  by  the 
digestive  derangement  ;  and  in  some  cases  to  actual 
increase  in  size  of  the  liver  and  spleen. 

The  enlargement  of  the  liver  and  spleen,  when  it  occurs, 
is  sometimes  combined  with  enlargement  and  induration 
of  the  lymphatic  glands  all  over  the  body.  The  superficial 
glands  may  be  felt  in  the  groins,  the  armpits,  and  the 
sides  of  the  neck,  as  hard,  round  freely  moveable  bodies, 
varying  in  size  from  a  pin's  head  to  a  sweet-pea.  The 
spleen  is  more  often  enlarged  than  the  liver,  and  some- 
times can  be  felt  as  a  solid  mass  which  passes  obliquely 
downwards  across  the  abdomen  so  as  almost  to  touch  the 
iliac  crest  on  the  right  side.  An  enlarged  spleen  is 
accompanied  by  the  characteristic  anaemia  and  there  may 
be  slight  oedema  of  the  extremities.  Examination  of  the 
blood  shows  decrease  in  the  red  corpuscles  but  no  positive 
increase  in  the  number  of  the  leucocytes. 

Mental  development  in  rickety  subjects  is  generally  said 
to  be  slow.  There  is  no  doubt  that  such  children  are  late 
in  talking  and  seem  to  be  slow  in  picking  up  new  words. 
I  believe,  however,  that  this  apparent  backwardness  is 
often  due,  not  to  deficiency  in  mental  capacity,  but  to  the 
indolence  which  is  apt  to  accompany  anaemia  and  weak- 
ness, for  in  general  intelligence  I  have  not  found  a  rickety 
child  to  be  below  the  average. 

Apart  from  all  the  physical  changes  produced  bj  the 
disease,  the  behaviour  of  a  rickety  child  is  very  charac- 
teristic, and  is  of  itself  almost  sufiicient  to  warrant  a 
diagnosis.    The  quiet,  the  repose  about  him,  strike  the 


138 


RICKETS 


observ^er  at  once.  Such  a  child,  if  able  to  sui:>port  himself, 
will  sit  for  hours,  his  legs  stretched  out  straight  before 
him  on  the  floor,  perfectly  contented  if  only  allowed  to 
remain  unnoticed.  All  that  he  wants  is  to  be  let  alone. 
A  healthy  child  delights  in  movement :  a  rickety  child  is 
only  happy  when  at  rest ;  his  greatest  pleasure  consists  in 
inaction.  To  look  at  him  we  are  irresistibly  reminded  of 
the  other  term  of  life,  for  he  apjjears  to  have  anticipated 
at  least  one  consequence  of  the  weight  of  years,  and  to 
have  combined  the  patient  endurance  of  old  age  with  the 
face  and  figure  of  a  child. 

Complications. — The  state  of  extreme  debility  to  which 
a  child  suffering  from  advanced  rickets  is  reduced  natu- 
rally favours  the  occurrence  of  secondary  diseases  in 
general ;  and  it  is  usually  to  one  of  these  that  death  is  to 
be  directly  attributed,  although,  in  some  cases,  the  in- 
tensity of  the  general  disease  may  be  of  itself  sufficient 
to  carry  off  the  patient.  Measles,  whooping-cough,  and 
scarlatina  are  very  liable  to  occur,  and  often  prove  fatal ; 
but  there  are  certain  other  diseases  which  are  especially 
predisposed  to  by  rickets,  viz.  : — 

Catarrh  and  bronchitis. 
Diarrhoea. 

Laryngismus  stridulus. 
Tetany  and  convulsions. 
Chronic  hydrocephalus. 
Scurvy. 

To  catarrh  and  hronchitis  are  due  a  very  large  proj^ortion 
of  the  deaths  in  this  disease. 

Bronchitis  is  an  extremely  fatal  disease  at  all  ages. 
The  mucus  which  is  thrown  into  the  tubes  impedes  the 
entrance  of  air :  but  unless  air  can  enter  freely  into  the 
vesicular  structure  of  the  lung  mucus  cannot  be  expelled. 
In  coughing  to  expel  the  mucus  the  lung  must  be  filled 
with  air  to  the  utmost ;  the  contained  air  is  then  prevented 


CATARRHAL  COMPLICATIONS 


139 


from  escaping  by  closure  of  the  glottis,  and  at  the  same 
time  pressure  is  brought  to  bear  upon  the  lungs  by  the 
muscles  of  expiration.  The  glottis  is  then  suddenly  opened 
and  the  air  is  driven  out,  carrying  with  it  the  mucus  which 
obstructed  the  tubes.  The  forced  respiration  seen  in 
persons  suffering  from  bronchitis  is  merely  the  effort 
made  to  draw  in  the  air  past  the  obstructing  mucus.  A 
second  impediment  to  the  entrance  of  air  into  the  lung  is 
found  also  in  the  healthy  child.  It  arises  from  the 
natural  flexibility  of  the  lower  part  of  the  thoracic  parietes 
which  yield  to  a  certain  extent  in  inspiration  before  the 
pressure  of  the  external  air.  In  advanced  rickets,  how- 
ever, this  natural  flexibility  is  greatly  increased  by  the 
abnormal  softening  of  the  ribs,  so  that  even  when  the 
lungs  are  healthy  each  inspiration  is  only  effected  by  a 
distinct  laborious  effort.  l^ow  add  bronchitis  to  this 
condition,  and  the  impediment  is  extreme.  Air  cannot 
enter  deeply  into  the  lungs  ;  mucus  cannot  be  expelled ; 
the  air,  however,  in  the  lungs  can  be,  and  is  expelled ; 
there  is,  consequently,  collapse,  and  the  child  dies — not 
properly  speaking  from  the  collapse,  but  from  that  which 
caused  the  collapse,  viz.,  the  inability  of  the  inspired  air 
to  pass  the  obstructing  mucus. 

The  extent  to  which  the  ribs  are  softened,  and  the 
amount  of  their  recession  in  inspiration,  are  therefore  of 
extreme  importance  as  regards  the  prognosis  of  bronchitis 
when  it  occurs  in  rickety  children. 

Diarrhoea. — Rickety  children  are  especially  liable  to 
attacks  of  purging.  This  may  be  accounted  for  partly  by 
their  extreme  sensitiveness  to  changes  of  temperature ; 
and  partly  by  the  unhealthy  condition  of  the  alimentary 
canal,  which  always  precedes  and  accompanies  the  disease, 
and  which  a  very  slight  additional  irritation  would  easily 
aggravate  into  diarrhoea.  These  attacks  are  exceedingly 
dangerous.  We  know  that  even  healthy  children,  seized 
with  profuse  purging,  rapidly  lose  flesh,  and  soon  beco 


140 


RICKETS 


exhausted.  A  few  hours  are  sufficient,  if  the  drain  is 
severe,  to  cause  a  marked  change  in  their  appearance  ; 
their  features  quickly  lose  the  roundness  of  youth,  and 
assume  instead  the  pinched,  drawn  characters  of  age 
E/ickety  children,  already  enfeebled,  are  still  less  able  to 
withstand  the  depressing  effects  of  the  disorder,  and  fall 
victims  to  it  all  the  more  readily  in  proportion  to  the  degree 
to  which  their  strength  has  been  previously  reduced. 

Laryngismus  stridulus,  tetany  and  convulsions  are  not 
uncommon  complications  of  rickets.  An  abnormal  irrita- 
bility of  the  nervous  system  appears  to  be  a  peculiarity 
of  the  rickety  constitution.  In  ordinary  cases  of  defective 
nutrition  no  such  nervous  irritability  is  observed,  nor  is 
a  convulsive  tendency  originated  by  long- continued  weak- 
ness. In  rickets,  however,  the  frequency  of  convulsions 
and  laryngismus  stridulus  is  undeniable.  The  latter 
derangement  is  rarely  met  with  apart  from  rickets  ;  while 
in  the  case  of  general  convulsions  nearly  half  the  children 
thus  affected  are  found  to  be  rickety.  =^ 

Some  authors  attribute  the  convulsive  tendency  to 
cranio-tabes.  Lederer,  out  of  ninety- six  cases  of  laryn- 
gismus, found  cranio-tabes  in  ninety-two.  Jacoby  has 
only  seen  one  case  of  laryngismus  stridulus  unassociated 
with  it.  Yogel  reports  a  case  in  which  spasm  of  the 
glottis  could  be  directly  produced  by  pressure  with  the 
finger  upon  the  softened  spots.  Hence  it  has  been  sug- 
gested that  the  spasmodic  symptoms,  which  often  come 
on  at  night,  are  the  direct  result  of  pressure  conveyed  to 
the  brain  as  the  child's  head  lies  upon  the  pillow.  What- 
ever may  be  the  value  of  the  explanation,  the  connection 
between  laryngismus  and  rickets  is  exceedingly  important 
as  regards  the  treatment  of  these  attacks.    Most  of  the 

*  Out  of  fifty  cases  of  laryngismus  noted  by  Dr.  Gee,  forty-eight 
were  rickety,  and  of  these  nineteen  had  general  convulsions;  out  of 
102  children,  in  whom  general  convulsions  occurred,  forty -six  were 
ty,  *St.  Bartholomew's  Hospital  Reports,*  vol.  iii,  1867. 


NERVOUS  COMPLICATIONS 


141 


children  in  whom  this  conclusiv^e  tendency  is  marked 
have  carpo -pedal  contractions. 

As  dentition  is  backward  in  all  these  cases  the  laryn- 
gismus and  the  convulsions  are  frequently  attributed  to 
teething.  The  teeth,  however,  are  quite  innocent  of  any 
share  in  the  production  of  these  complications.  They  are 
backward  as  a  consequence  of  the  arrest  of  growth  of 
bone,  which  is  one  of  the  characteristics  of  the  disease. 
When  the  teeth  do  appear  they  are  often  cut  with  re- 
markable ease,  and  whereas  the  child  had  been  formerly 
subject  to  convulsions,  with  or  without  apparent  cause, 
the  beginning  of  dentition  is  accompanied  by  no  such 
phenomena  ;  the  removal  of  the  rickety  condition,  as 
shown  by  the  eruption  of  the  teeth,  being  coincident  with 
the  disappearance  of  the  spasmodic  tendency. 

In  not  a  few  cases  I  believe  the  nervous  commotion  to 
be  the  direct  consequence  of  post  nasal  irritation.  Adenoid 
growths  in  the  naso-pharynx  are  common  enough  in 
infancy,  and  serious  nerve  worry  may  be  set  up  by  them. 
I  have  seen  so  many  cases  of  laryngeal  stridor  and  spasm 
put  an  end  to  by  removal  of  these  vegetations  that  when- 
ever these  symptoms  prevail  I  make  it  my  first  care  to 
ascertain  the  condition  of  the  nasal  passages. 

The  proneness  to  convulsions  of  the  subjects  of  rickets 
must  be  always  kept  in  mind,  as  by  it  we  may  sometimes 
explain  the  occurrence  of  eclampsia  during  the  progress 
of  various  acute  diseases.  Thus,  in  whooping-cough  a 
convulsive  attack  may  be  an  event  of  the  utmost  gravity, 
as  it  may  arise  from  cerebral  embolism  or  announce  the 
beginning  of  a  serious  inflammatory  complication.  In  a 
rickety  child,  however,  a  nervous  seizure  in  the  course  of 
whooping-cough  may  be  induced  by  gastric  derangement 
or  some  unimportant  form  of  reflex  irritation.  If,  then, 
in  such  a  case  we  find  well-marked  signs  of  rickets,  and 
notice  after  the  fit  that  the  expression  of  the  patient  shows 
no  additional  distress,  and  that  there  are  no  signs  of  lung 


142 


RICKETS 


complication,  we  may  speak  hopefully  of  his  chances  of 
recovery. 

The  primary  cause  of  the  convulsive  tendency  in  rickets 
appears  to  be  the  imperfectly  nourished  state  of  the 
central  nervous  system,  the  brain  and  spinal  cord  neces- 
sarily sharing  in  the  mal-nutrition  which  affects  all  the 
organs  of  the  body.  Often — probably  in  most  cases — as 
nutrition  is  restored,  the  convulsive  tendency  subsides, 
leaving  the  child  free  from  any  form  of  neurosis.  It  is 
said,  however,  that  this  perfect  freedom  from  after  ill- 
consequences  should  not  be  relied  upon  too  confidently. 
Some  observers  profess  to  see  a  connection  between  con- 
vulsions in  early  childhood  and  epilepsy  in  later  life,  and 
hold  that  the  damage  suffered  by  the  brain  during  the 
rachitic  j)eriod  may  be  something  more  than  a  merely 
temporary  injury.  Thus,  Sir  W.  Growers  found  that 
10  per  cent,  of  a  given  number  of  epileptics  had  had 
convulsions  in  infancy.  Dr.  J.  A.  Coutts  would  place  the 
percentage  from  his  own  observations  as  high  as  17.  As 
infantile  convulsions  are  especially  apt  to  occur  in  rickety 
children,  it  is  assumed  that  in  these  cases  the  epilepsy  was 
a  natural  expression  of  the  cerebral  mal-nutrition  found 
in  rickets,  and  was  therefore  a  direct  consequence  of  that 
disease.  But  evidence  furnished  by  statistics  such  as 
these  is  by  no  means  conclusive.  So  many  children  suffer 
from  rickets  in  a  more  or  less  pronounced  form  that  any 
disease  which  could  be  named,  or  even  any  accidental 
injury,  might  by  such  reasoning  be  ascribed  to  the  after 
effects  of  mal-nutrition  in  infancy.  Evidence  of  a  more 
trustworthy  character  than  this  is  required  before  such  a 
conclusion  can  be  accepted  as  the  true  one. 

Chronic  hydrocephalus  occasionally  complicates  the  dis- 
ease between  the  ages  of  eight  and  eighteen  months.  The 
fluid  may  be  in  the  lateral  ventricles,  in  the  arachnoid 
sac,  or  in  both.  It  often  appears  to  be  a  merely  mechani- 
cal effusion,  the  serosity  being  thrown  out  to  fill  up  the 


SCURVY 


143 


space  left  when  the  cranial  cavity  becomes  enlarged  with- 
out any  corresponding  increase  in  the  size  of  the  brain. 
In  these  cases  the  convolutions  are  perfectly  natural,  and 
show  no  signs  of  pressure. 

On  account  of  the  altered  shape  of  the  skull,  hydro- 
cephalus is  often  suspected  where  it  does  not  really  exist. 
The  differences  between  the  ordinary  rickety  head,  and 
the  skull  expanded  by  fluid  in  its  cavity,  have  already 
been  pointed  out.    (See  page  125.) 

Scurvy  is  an  occasional  and  important  complication  of 
rickets.  The  impoverishment  of  the  blood  to  which  the 
scorbutic  symptoms  are  due  may  be  dependent  upon  the 
same  conditions  which  produced  the  primary  disease,  for 
scurvy  and  rickets  may  be  both  consequences  of  bad  feed- 
ing and  unhealthy  surroundings.  But  while  the  latter  is 
an  outcome  of  general  malnutrition,  the  former  is  the  re- 
sult of  the  absence  from  the  blood  of  some  special  consti- 
tuent. If  this  be  supplied  the  child  remains  free  from 
scurvy,  however  imperfect  may  be  the  nutrition  of  his 
system  generally.  When  scurvy  occurs,  the  disease  ap- 
pears in  children  who  have  been  fed  largely  upon  con- 
densed milk  and  tinned  foods.  So  long  as  the  child  is 
taking  fresh  cow's  milk,  he  can  never  become  scorbutic.'^ 

Scurvy,  when  seen  in  the  child,  presents  peculiar 
characters.  The  gums  are  not  always  affected.  The 
principal  symptoms  are  dependent  upon  sub-perio steal 
extravasation  of  blood.  This  extravasation  usually  occurs 
at  the  lower  parts  of  the  thighs  and  around  the  knee 
joints.  Sometimes,  also,  the  ends  of  the  long  bones  be- 
come separated  from  the  shaft.  As  a  consequence  there 
is  extreme  tenderness  of  the  limbs,  which  at  once  strikes 

^  The  statement  in  the  text  refers  only  to  perfectly  fresh  cow's 
milk,  which  has  undergone  no  manipulation  in  the  nursery.  I  have 
seen  well  marked  symptoms  of  scurvy  in  a  child  of  twelve  months'* 
old,  who  was  being  brought  up  on  "artificial  human  milk,"  with  an 
occasional  meal  of  gravy  or  beef-tea  and  bread  crumb. 


144 


RICKETS 


the  observer  as  something  quite  beyond  the  usual  tender- 
ness of  a  rickety  child.  The  limb  swells  at  the  site  of  the 
lesion,  and  is  excessively  tender.  The  child  seems  to 
suffer  from  constant  pain,  for  he  lies  moaning  in  his  cot> 
and  cannot  bear  the  slightest  touch  upon  the  swollen  part. 
The  latter  is  seen  to  be  enlarged  and  sometimes  oedema- 
tous.  It  may  occupy  the  whole  of  the  thigh  or  leg,  or 
may  be  more  circumscribed.  The  upper  limbs  are  com- 
paratively larely  affected.  In  addition  to  the  swellings, 
petechise  and  bruise-like  patches  may  be  present,  and 
sometimes  unhealthy-looking  sores  are  noticed  on  the 
skin.  If  separation  of  epiphyses  takes  place,  the  child, 
instead  of  keeping  his  limbs  flexed,  as  at  first,  allows  them 
to  lie  stretched  out  as  if  paralysed.  When  this  stage  is 
reached,  the  pain  and  tenderness  have  usually  greatly 
diminished.  In  exceptional  cases  the  gums  are  spongy, 
but  if  the  child  be  suffering  from  marked  rickets,  the  gums 
are  rarely  affected  to  any  great  extent. 

Usually,  certain  general  symptoms  accompany  the  de- 
velopment of  the  local  phenomena.  The  temperature  rises 
to  101°  or  102^^  in  the  evening,  and  the  child  sweats  pro- 
fusely. His  complexion  is  excessively  pale  with  a  sallow 
tint,  and  his  debility  is  extreme.  The  urine  may  contain 
albumen,  and  is  sometimes  tinged  with  blood. 

The  swellings  first  noticed  sometimes  disappear,  to  be 
followed  by  secondary  swellings  in  other  parts ;  and 
sometimes  the  symptoms  pass  off  completely  for  a  time, 
to  return  after  a  period  of  months. 

When  under  appropriate  treatment  recovery  takes  place 
it  is  complete.  The  local  thickening  which  persists  after 
the  swelling  has  subsided  gradually  disappears,  and  even 
the  separated  epiphyses  become  again  united  with  the 
shaft  of  the  bone. 

The  conjunction  of  scurvy  and  rickets  has  been  de- 
scribed by  Filrst  and  others  under  the  name  of  acute 
rickets."    The  scorbutic  nature  of  the  complication  has, 


MODE  OF  ENDING 


145 


however,  been  amply  demonstrated  by  Drs.  Clieadle  and 
T.  Barlow. 

Besides  the  complications  which  have  been  mentioned, 
acute  tuberculosis  may  occur  in  rickety  children.  This, 
however,  is  not  a  special  complication  of  the  disease,  and 
is  comparatively  rare. 

When  rickets  ends  fatally,  death  occurs  as  a  consequence 
of  one  of  the  above  complications.  Tn  extreme  cases  the 
child  gets  so  weak  that  he  can  no  longer  support  himself, 
but  lies  down  or  is  propped  up  with  pillows  in  his  cot.  He 
breathes  with  difficulty  on  account  of  the  softened  state  of 
his  ribs,  and  his  face  grows  livid  or  lead  coloured.  In  this 
state  his  power  of  resisting  injurious  influences  is  quite 
lost  and  his  hold  upon  life  feeble  in  the  extreme.  Any 
additional  source  of  weakness — trifling  enough,  perhaps, 
in  itself — may  prove  more  than  he  can  bear ;  and  he  suc- 
cumbs to  a  little  looseness  of  the  bowels  or  to  collapse  of 
lung  induced  by  a  mild  pulmonary  catarrh. 

If  the  disease  terminate  favourably,  the  symptoms 
gradually  subside,  and  finally  disappear.  The  tenderness 
becomes  less  marked  ;  the  bones  cease  to  soften  ;  the  child 
appears  more  lively,  and  takes  an  interest  in  what  passes 
around  him.  As  the  softening  of  the  ribs  diminishes,  his 
respiration  growls  less  laborious,  and  he  will  then  begin  to 
amuse  himself  with  his  toys.  The  appetite  improves,  and 
gets  less  capricious ;  the  bowels  are  more  regular,  and  the 
stools  healthier-looking.  The  wasting  ceases  ;  the  child 
begins  to  gain  flesh,  while  the  belly  decreases  in  size,  and 
becomes  less  prominent.  The  head- sweats  are  less  noticed, 
and  his  sleep  at  night  is  more  tranquil,  although  for  a  long 
time  he  will  continue  to  throw  off  the  bed-clothes  at  night 
unless  restrained.  Dentition  is  resumed,  and  goes  on 
rapidly  and  easily.  The  deformities  of  the  bones  gra- 
dually diminish  ;  the  bones  get  very  much  straighter  than 
would  be  expected  from  their  former  distortion,  become 
exceedingly  thick  and  strong,  and  the  enlargement  of  the 

10 


146 


RICKETS 


ends  of  the  long  bones  becomes  very  remarkably  reduced. 
The  muscles  also  begin  to  be  more  developed,  and  increase 
rapidly  in  size.  The  increase  in  length  of  the  bones, 
however,  is  not  rapid,  and  the  child  remains  more  or  less 
stunted,  seldom  when  full  grown  reaching  the  average 
height. 

In  cases  of  recovery  from  advanced  rickets  we  some- 
times find  that  at  the  very  time  when  the  deformity  of 
the  chest  is  becoming  obviously  less  the  legs  of  the  child 
begin  to  bend,  although  up  to  that  period  they  had  been 
straight.  This  seeming  contradiction  is  apparently  due 
to  the  fact  that  as  nutrition  improves  and  the  disease  sub- 
sides, muscular  power  increases.  The  child  then  begins 
to  make  more  use  of  his  legs.  As  soon  as  his  strength 
allows  he  begins  to  get  upon  his  feet,  to  stand  and  to 
walk.  Consequently,  his  bones,  as  yet  hardly  consolidated, 
bend  under  the  weight  of  his  body. 

The  rapidity  with  which  dentition  proceeds  during 
recovery  is  sometimes  very  striking,  and  is  well  illustrated 
by  the  following  case.  Gleorge  P.  at  the  age  of  two  years 
had  but  twelve  teeth,  and  could  not  stand.  The  chest 
was  much  deformed,  the  ends  of  the  long  bones  were 
enlarged,  and  the  legs  were  very  thin  and  flabby.  Treat- 
ment was  begun  on  November  29.  On  January  24  of  the 
following  year,  the  boy  could  walk  across  the  room  steady- 
ing himself  by  the  different  articles  of  furniture,  and  by 
May  16  could  walk  well  and  firmly  without  any  assistance. 
The  teeth  appeared  as  follows : — By  April  7,  he  had  cut 
the  two  upper  canines,  and  by  May  16,  the  two  lower 
canines  ;  by  May  80,  three  back  molars  had  appeared, 
and  on  the  following  day,  June  1,  the  last  remaining  tooth 
pierced  the  gum.  The  treatment  consisted  in  careful 
regulation  of  his  diet ;  in  the  administration  of  alkalies 
with  drop  doses  of  tinct.  opii,  to  improve  the  condition  of 
his  digestive  organs ;  and  afterwards,  when  the  motions 


PATHOLOGY 


147 


were  perfectly  healthy,  in  iron  wine  with  half-clrachm 
doses  of  cod's  liver  oil. 

Pathology. — Rickets  is  a  general  disease,  and  affects  very 
widely  the  tissues  of  the  body.  Its  influence  is  most 
manifest  in  the  bones,  which  are  always  implicated,  but 
we  find,  in  addition,  changes  in  the  brain,  liver,  lymphatic 
glands,  spleen,  muscles,  and  often  in  every  organ  in  the 
body. 

Rickets  affects  the  bones  in  three  ditferent  ways. 

It  interferes  with  their  growth,  not  only  temporarily,  but 
permanently ;  for  children  who  have  been  thus  affected 
never,  as  Mr.  Shaw  has  pointed  out,  grow  into  average- 
size  adults. 

It  interferes  with  their  development,  delaying  the  pro- 
cess of  ossification,  and  rendering  the  calcareous  deposit 
irregular  and  incomplete.  There  is  great  proliferation 
of  the  cartilages  at  the  end  of  the  bones,  and  of  the 
periosteum ;  but  here  a  pause  takes  place,  and  the  further 
step  in  the  process,  the  actual  deposition  of  earthy  salts, 
is  very  slowly  carried  on. 

But  besides  its  influence  over  the  growth  and  develop- 
ment of  bone,  rickets  produces  equally  serious  changes 
in  bone  already  completely  ossified.  The  previously  hard 
bone  becomes  softened  :  it  may  be  bent  with  ease,  and  can 
be  cut  with  a  knife,  like  a  carrot.  The  softening  is  not 
due,  as  was  at  one  time  supposed,  to  a  removal  of  lime- 
salts  previously  deposited.  It  is  not  that  hard  tissue 
becomes  soft,  but  that  new  soft  tissue  is  slow  to  harden. 
In  healthy  growth  of  a  long  bone  new  osseous  tissue  is 
being  constantly  added  to  the  surface,  while  a  correspond- 
ing absorption  takes  ]3lace  from  the  interior.  In  rickets, 
however,  although  the  proliferation  of  the  periosteum  is 
extreme,  this  new  matter  does  not  undergo  the  usual  ossifi- 
cation. The  natural  enlargement  of  the  medullary  canal 
continues,  however,  as  in  health.  But  as  the  loss  of  bone 
from  within  is  not  compensated  for  by  the  normal  forma- 


148 


RICKETS 


tioii  of  new  osseous  matter  at  the  circumference,  the  pro- 
portion of  bony  tissue  is  constantly  diminishing,  while 
that  of  new  soft  matter  proliferated  from  the  periosteum 
is  constantly  on  the  increase. 

Many  theories  have  been  devised  to  account  for  the 
disease,  and  the  structural  peculiarities  which  arise  from 
it ;  but  none  of  these  can  be  considered  satisfactory.  The 
proliferation  of  the  cartilages  and  the  periosteum  has  been 
attributed  to  inflammatory  action.  The  delay  in  the  de- 
position of  earthy  salts  has  been  explained  by  supposing 
them  to  be  held  in  solution  by  free  acids,  chiefly  lactic, 
existing  in  the  blood  of  the  patient,  and  generated  by 
fermentation  of  food  in  the  digestive  organs.  All  this, 
however,  is  mere  hypothesis.  The  inflammatory  theory  is 
corroborated  neither  by  the  anatomical  characters  nor  the 
clinical  history  of  the  disorder;  and  with  regard  to  the 
formation  of  acid,  rickets  is  not  always  preceded  by  attacks 
of  acid  dyspepsia,  nor  is  the  increase  of  lactic  acid  or  of 
phosphate  of  lime  in  the  urine  by  any  means  a  constant 
feature  of  the  complaint.  Besides,  it  is  not  only  that  the 
process  of  ossification  is  retarded :  it  is  also  perverted. 
Calcareous  matter  is  found  dej^o sited  in  abnormal  situa- 
tions ;  indeed,  the  process  has  been  compared  by  Sir 
William  Jenner  to  the  petrifaction  we  see  occasionally 
taking  place  in  enchondromata. 

Mercoli  advocates  the  microbic  origin  of  rickets,  and 
believes  the  disease  to  be  induced  by  a  process  of  auto- 
infection  with  ordinary  pyogenic  organisms.  According  to 
this  observer,  streptococci  and  staphylococci  are  absorbed 
from  the  alimentary  canal  into  the  blood  and  become 
arrested  in  the  organs.  They  tend  especially  to  visit  the 
parts  where  the  greatest  functional  activity  is  in  progress. 
These,  in  the  infant,  are  the  nervous  system  and  the 
epiphysial  ends  of  the  long  bones.  Mercoli,  in  his  experi- 
ments upon  young  rabbits,  found  that  the  injection  of 
these  microbes  into  the  bones  and  epiphysial  cartilages  set 


MORBID  ANATOMY 


149 


up  in  some  cases  a  common  osteomyelitis.  In  others, 
however,  it  induced  an  osteomyelitis  without  trace  of 
suppuration,  but  with  hypertrophy  of  the  ends  of  the 
long  bones  and  articular  cartilages,  such  as  we  find  in 
rickets,  with  serious  consequences  to  the  general  nutrition 
of  the  animal. 

Morbid  Anatomy. — The  enlargement  of  the  ends  of  the 
long  bones  is  a  real  hypertrophy.  Great  preparations  are 
made  for  the  process  of  ossification.  The  cartilage  cells 
enlarge  and  subdivide,  not  only  in  the  immediate  neigh- 
bourhood of  the  calcareous  deposit,  but  also  at  a  consider- 
able distance  from  it.  Hence  the  proliferating  zone  instead 
of  forming  a  narrow  reddish- grey  strip  between  the  carti- 
lage and  the  bone,  such  as  is  seen  in  natural  ossification, 
appears  as  a  broad  grey  band  which  may  reach  from  a 
quarter  to  half  an  inch  in  width.  A  similar  exaggeration 
of  the  normal  condition  is  seen  in  the  shafts  of  the  long 
bones  and  in  the  flat  bones.  Here  the  proliferating  layer 
of  the  periosteum  is  also  unnaturally  thick.  It  forms 
broad,  flat  uniform  elevations  on  the  surface  of  the  bone, 
and  these  in  the  case  of  the  cranial  bones  are  sharply 
circumscribed.  The  newly-formed  tissue  is  bright  red 
from  excessive  vascularity. 

While  every  preparation  is  thus  made  for  the  reception 
of  the  calcareous  deposit  and  the  formation  of  osseous 
tissue,  the  actual  conversion  of  the  new  material  into  bone 
takes  place  very  slowly  and  imperfectly.  The  advancing 
bone,  instead  of  penetrating  in  a  regular  line  into  the 
cartilage,  developing  medullary  spaces  in  the  normal 
manner,  strikes  up  at  different  points,  leaving  the  car- 
tilage at  other  points  still  uncalcified,  and  these  may 
remain  untouched  by  the  earthy  impregnation,  forming 
specks  of  cartilage  completely  surrounded  by  bone.  The 
line  of  medullary  spaces  also  shows  the  same  irregularity. 
We  find  them  not  only  in  their  normal  situation  just  below 
the  margin  of  calcification,  but  also  penetrating  into  the 


150 


RICKETS 


proliferating  cartilage,  far  in  advance  of  the  line  of  earthy 
deposit.  These  spaces  are  filled  with  soft  vascular  tissue, 
and  are  apparently  intended  to  supply  nutritive  material 
to  both  the  proliferated  and  non-proliferated  portions  of 
the  cartilage. 

The  calcareous  impregnation  takes  place  in  the  cartilage 
cells  before  the  matrix  is  attacked.  The  changes  in  it  can 
therefore  be  observed  with  especial  distinctness,  on  account 
of  the  absence  of  the  usual  deposition  of  granular  cal- 
careous particles  from  the  matrix  at  the  border  of  ossifica- 
tion. The  capsule  of  the  cell  becomes  thicker  and  thicker, 
gradually  encroaching  upon  its  cavity.  At  the  same  time 
canalicular  pores  are  formed  in  the  thickened  wall.  At 
last  a  vacant,  irregularly- shaped  space,  closely  resembling 
a  lacuna  of  bone,  is  all  that  is  left  of  the  cavity  of  the  cell. 
Scattered  through  the  matrix  are  often  seen  rough  white 
particles  like  isolated  masses  of  lime.    These  spots  of 

provisional  calcification  "  are  sometimes  sufficiently 
numerous  to  give  a  dotted  appearance  to  a  section  of  the 
cartilage. 

In  the  case  of  the  flat  bones  and  the  shaft  of  the  long- 
bones,  when  the  sub-periosteal  exudation  becomes  con- 
verted into  bone,  the  trabeculse  are  at  first  extremely  thin, 
and  the  new  osseous  tissue  remains  for  a  long  period 
unusually  porous  and  vascular.  Eventually,  however,  it 
becomes  denser,  and  is  transformed  into  a  tissue  of 
extreme  solidity  and  hardness. 

So  long  as  the  disease  is  in  progress,  the  bones  lose 
more  and  more  of  their  firmness,  getting  softer  and  softer. 
This  softening  of  the  bones  is  due,  as  has  been  already 
described,  to  the  gradual  absorption  of  bony  tissue  from 
the  interior,  and  the  continued  proliferation  on  the  surface 
of  new  soft  matter  which  is  slow  to  calcify.  The  conse- 
quence is  that  the  bones  bend,  or  perhaps  more  commonly 
break  on  one  side,  like  a  stick  of  green  wood. 

When  the  disease  becomes  arrested  consolidation  begins, 


CRANIO-TABES 


151 


and  the  bones  acquire  greater  firmness  and  consistency. 
The  process  of  consolidation  has  been  compared  to  the 
calcification  of  callus  in  ordinary  fractures.  In  the  long 
bones  calcareous  nuclei,  the  rudiments  of  ncAv  bony  tissue, 
appear  in  the  greasy  gelatinous  matter  deposited  beneath 
the  periosteum  at  the  circumference  of  the  shaft.  These 
enlarge  and  unite ;  the  layers  of  bone  get  thicker  and 
thicker;  and  the  new  tissue,  thus  acquiring  consistence, 
hardens  gradually  into  a  compact  substance  like  ivory. 
In  the  flat  and  short  bones  the  effused  matter  is  partially 
absorbed,  so  as  to  restore  the  normal  spongy  tissue. 

The  occipital  bone  sometimes  differs  from  the  other 
bones  of  the  skull  in  being  the  seat  of  a  special  change. 
In  the  condition  called  cranio-tabes,  spots  are  found  in 
this  bone  where  the  osseous  tissue  is  thin,  transparent, 
of  a  yellowish-red  colour,  and  contains  scarcely  any  spongy 
substance.  By  holding  the  bone  against  the  light  the 
extent  of  the  thinning  can  be  readily  seen.  When  looked 
at  from  the  inside,  depressions  are  found  which  correspond 
to  the  underlying  convolutions  of  the  brain.  Yogel  divides 
the  process  by  which  these  changes  take  place  into  two 
stages  ;  a  first  stage,  in  which  there  is  deficient  deposition 
of  phosphates  in  the  external  bony  layers  all  over  the 
skull ;  and  a  second  stage,  in  which  absorption  takes  place 
in  the  softened  parts  where  the  pressure  of  the  brain  is 
felt.  Sometimes  the  thinning  of  the  bone  is  so  extreme 
that  the  osseous  tissue  almost  entirely  disappears  in  the 
affected  spots ;  the  pericranium  and  the  dura  mater  then 
come  into  contact,  having  between  them  merely  relics  of 
bone  still  unabsorbed. 

Analysis  of  rickety  bone  shows  that  the  bone  contains 
79  parts  of  organic  to  21  of  inorganic  matter,  the  propor- 
tions thus  differ  very  much  from  those  existing  in  healthy 
bone,  where  the  inorganic  matters  are  largely  in  excess  of 
the  organic,  being  as  63  to  37. 

Moreover,  the  animal  matter  yields  no  gelatin  on  boiling, 


152 


RICKETS 


and  at  an  advanced  period  of  the  disease  is  said  by  Simon 
to  yield  neither  gelatin  nor  chondrin.  Schlonberger  and 
Friedleben  have  obtained  perfect  gluten  from  rickety  bone. 

The  softening  of  the  ribs,  and  consequent  deformity 
of  the  chest,  produces  certain  morbid  conditions  in  the 
contents  of  the  thoracic  cavity.  The  influence  exercised 
by  the  softened  ribs  upon  the  course  and  termination  of 
bronchitis  has  already  been  described ;  but  there  are, 
besides,  two  special  lesions  of  the  lung,  which  are  invari- 
ably present,  and  always  in  the  same  situation  in  every  case 
of  rickety  chest-distortion.  These  lesions  are  emphysema 
and  collapse. 

The  emphysema  occupies  the  whole  length  of  the 
anterior  border  of  each  lung,  extending  backwards  for 
about  three-quarters  of  an  inch  from  the  free  margin. 
The  mode  of  its  production  is  explained  in  the  following 
way.  At  each  inspiration  the  ribs  sink  in,  and  the  lateral 
diameter  of  the  chest  is  narrowed  at  the  part  corresponding 
to  the  line  of  union  of  the  ribs  with  their  cartilages. 
While,  however,  the  lateral  diameter  is  thus  diminished, 
the  antero-posterior  diameter  is  increased  by  the  thrusting 
forwards  of  the  sternum.  Air,  therefore,  is  forced  in 
excess  into  the  lungs  at  that  part  so  as  to  fill  up  the 
resulting  space,  and  thus  induces  over-distention  of  the  air 
vesicles. 

Collapse  of  the  lung  is  produced  by  the  recession  of 
the  ribs  during  inspiration.  The  collapsed  portion  forms 
a  groos^e  just  outside  the  emphysematous  part,  separating 
it  from  the  healthy  lung.  This  groove  corresponds  to  the 
line  of  nodules  which  represent  the  enlarged  ends  of  the 
ribs,  and  which  project  inwards  into  the  interior  as  much 
as,  or  even  more  than,  they  project  exteriorly.  During 
inspiration  the  ribs  sink  in,  and  the  nodules  are  forced 
against  the  lung  beneath  them,  so  that  they  compress  the 
pulmonary  lobules  at  those  points,  and  close  them  against 
the  advancing  air. 


WHITE   PATCH  " 


153 


These  two  lesions  are,  therefore,  quite  independent  one 
of  another  ;  and  although  they  invariably  occur  if  there 
is  much  softening  of  the  ribs,  yet  they  do  not  stand  to 
one  another  in  the  relation  of  cause  and  effect. 

The  collapse  which  is  sometimes  found  to  occupy  the 
posterior  and  inferior  parts  of  the  lung  and  occasionally 
some  parts  of  the  upper  lobes,  is  the  result  of  plugging  of 
a  tube  with  mucus.  The  mechanism  of  this  has  already 
been  described.    It  is  only  found  in  bronchitis. 

Another  result  of  the  rickety  chest  is  the  circumscribed 
opacity  of  the  visceral  surface  of  the  pericardium,  known 
by  the  name  of  "  white  patch."  This,  although  uncom- 
mon in  children  generally,  is  very  common  in  rickety 
children.  Its  seat  is  usually  the  left  ventricle,  a  little 
above  its  apex,  just  at  the  point  where  the  heart  at  each 
beat  comes  in  contact  with  the  nodule  of  the  fifth  rib.  In 
this  case  friction  against  the  bone  is  evidently  the  cause 
of  the  white  patch,  and  this  is  a  strong  argument  in  favour 
of  the  attrition  theory  "  generally.  The  same  thing  is 
often  seen  on  the  spleen,  which,  rising  and  falling  with 
respiration,  is  rubbed  against  a  projecting  rib  nodule. 
It  is  distinguished  from  the  result  of  embolism  by 
not  extending  deeper  than  the  fibrous  coating  of  the 
organ. 

Pathological  changes  occasionally  take  place  as  a  result 
of  rickets  in  the  lymphatic  glands,  liver,  spleen,  and  other 
internal  organs.  All  the  organs  are  tough  and  solid  to 
the  touch,  and  are  heavy  out  of  proportion  to  their  size. 
The  changes  they  undergo  appear  to  be  analogous  to  those 
which  occur  in  the  bones.  They  are  not  dependent  upon 
any  foreign  growth  or  deposit  in  the  tissues,  but  consist 
in  an  irregular  hypertrophy  of  their  fibroid  and  epithelial 
elements  with,  at  the  same  time,  a  deficiency  in  their 
earthy  salts. 

The  liver  is  sometimes  enlarged,  but  often  it  only  seems 
to  be  so  through  the  contraction  of  the  chest  which  causes 

i 

./ 


154 


RICKETS 


it  to  be  pressed  down  from  its  natural  position.  Any 
increase  in  size  is  due  in  the  majority  of  cases  to  a  develop- 
ment of  the  fibrous  tissue,  and  to  a  less  extent  of  the 
cellular  elements  of  the  gland,  with  deficiency  in  the  salts. 
Owing  to  these  changes  the  density  of  the  organ  is  greatly 
increased  and  it  feels  unusually  firm  to  the  touch. 

The  diseased  spleen  varies  very  much  in  size.  Some- 
times it  can  just  be  felt  below  the  ribs  ;  but  often  it  pro- 
jects downwards  into  the  abdomen  as  low  as  the  level  of 
the  umbilicus.  It  may  measure  as  much  as  eight  inches 
from  above  downwards,  and  four  inches  from  side  to  side. 
The  organ  is  hard  and  resistant,  and  its  substance  is  tough 
and  elastic,  so  that  thin  sections  can  be  cut  without  diffi- 
culty. The  changes  which  occur  in  it  are  due  to  fibrosis, 
as  in  the  case  of  the  liver.  The  trabeculse  are  seen  to  be 
swollen  irregularly,  and  the  threads  forming  the  meshes 
are  thicker  than  natural,  often  as  thick  as  the  spaces  they 
enclose.  At  the  same  time  there  is  abnormal  development 
of  the  contents  of  the  meshes,  and  the  corpuscles  are 
crowded  together. 

The  lymphatic  glands,  especially  those  of  the  mesentery, 
are  apt  to  be  enlarged  and  hard.  On  section  they  are 
white  and  opaque,  from  accumulation  of  their  cellular  and 
corpuscular  contents. 

These  changes  are  not  present  in  every  case  of  rickets  ; 
a.nd  the  organs,  even  when  enlarged,  are  not  always 
increased  in  size  as  a  result  of  the  lesions  above  described. 
In  rickety  children  who  are  much  enfeebled  and  wasted 
by  long- continued  intestinal  catarrh  the  liver  is  often 
found  to  be  swollen  from  fatty  infiltration.  In  other 
cases,  if  the  child  has  suffered  from  chronic  interference 
with  the  function  of  the  lungs  from  repeated  attacks  of 
pulmonary  catarrh,  a  chronic  congestion  of  the  liver  is 
induced  which  gives  rise  to  considerable  enlargement. 
The  spleen,  again,  may  be  simply  hypertrophied,  under- 
going a  change  similar  to  that  which  is  often  seen  in  cases 


MORBID  ANATOMY 


156 


of  inherited  syj)liilis,  or  in  children  suffering  from  the 
ague  cachexia.  Like  the  liver,  too,  it  may  be  swollen  from 
chronic  congestion. 

The  brain  is  usually  larger  than  natural :  but  the  in- 
crease is  apparently  due  in  many  cases  to  a  true  hyper- 
trophy. In  a  case  noted  by  Dr.  Gee,  this  organ  weighed 
fifty-nine  ounces  ;  it  was  of  natural  consistence,  not 
toughened  or  hardened,  and  the  grey  and  white  matter 
appeared  to  retain  their  normal  proportions.  In  another 
case,  the  brain  weighed  forty-two  and  a  half  ounces,  and 
also  seemed  healthy,  although  of  such  unusual  size.  The 
disease  is  said  to  be  in  the  neuroglia,  not  in  the  nerve 
elements. 

The  voluntary  muscles  are  small,  pale,  flabby,  and  soft, 
but  do  not  owe  this  appearance  to  fatty  degeneration,  for 
there  is  no  excess  of  olein.  Under  the  microscope  their 
fibres  are  softer  and  paler  than  natural,  with  the  striae 
very  indistinctly  marked. 

The  urine  in  rickets  is  pale.  The  amount  of  urea  and 
uric  acid  is  diminished ;  but  there  is  increase  in  the 
amount  of  the  earthy  phosphates.  This  increase  is  stated 
to  be  greatest  at  the  beginning  of  the  bone  softening,  and 
to  become  less  marked  when  the  disease  is  further  ad- 
vanced and  the  bones  are  undergoing  distortion.  Free 
phosphoric  and  lactic  acids  have  been  observed,  and  it  is 
not  uncommon  to  find  a  sediment  of  oxalate  of  lime.  In 
cases  where  sweating  is  profuse  the  diminished  secretion 
of  water  by  the  kidneys  may  cause  such  concentration  of 
urine  that  uric  acid  sand  is  deposited.  This  is  especially 
likely  to  happen  if  the  child  be  at  the  same  time  suffering 
from  acidity,  the  result  of  fermentation  of  food. 

From  the  above  description  it  will  be  seen  that  rickets 
is  not  merely  a  disease  of  the  bones,  but  one  which  affects 
the  tissues  of  the  body  very  widely.  Of  late,  considerable 
attention  has  been  given  to  cases  of  bony  deformity  in  the 
child,  and  it  has  been  asserted  that  in  some  instances  in 


156 


RICKETS 


which  extensive  osseous  changes  have  been  noticed  in  the 
young  subject  the  lesion  is  more  allied  to  osteomalacia 
than  to  true  rickets.  The  two  conditions  are  essentially 
dissimilar,  for  while  in  rickets  ossification  is  imperfect 
from  arrested  calcification  of  new  bone-forming  material, 
in  osteomalacia  softening  is  the  consequence  of  re-absorp- 
tion of  the  lime  salts  from  bone  completely  ossified.  Dr. 
Rehn  of  Frankfort  has  reported  the  case  of  a  little  girl, 
aged  eighteen  months,  in  whom  there  was  much  softening 
of  the  long  bones,  but  the  epiphysial  ends  were  only 
enlarged  to  a  very  slight  degree,  and  in  the  bones  of  the 
lower  limbs  were  apparently  normal.  Those  bones,  also, 
were  quite  straight,  and  the  whole  skeleton  was  exces- 
sively thin.  For  these  reasons  Dr.  Rehn  was  disposed  to 
believe  that  the  lesions  ought  rather  to  be  classed  under 
the  heading  of  osteomalacia  than  under  that  of  rickets, 
although  a  rickety  element  in  the  case,  shown  by  a  con- 
siderable formation  of  sub-periosteal  deposit,  was  admitted. 
The  question  is  one  of  great  interest  to  the  pathologist, 
but  requires  further  observations  for  its  elucidation. 

Diagnosis. — The  early  diagnosis  of  rickets  is  of  great 
importance,  for  the  disease  if  taken  in  time  is  cured 
without  difficulty.  Plumpness  is  no  proof  of  the  absence 
of  rickets,  for  a  child  may  be  extremely  fat,  and  yet 
rickety ;  on  the  other  hand,  wasting  is  no  proof  of  its 
presence,  for  a  child  may  be  reduced  almost  to  a  skeleton 
without  presenting  a  single  symptom  of  the  disease. 

In  a  well  marked  case  of  rickets  the  head  elongated 
from  before  backwards  ;  the  square,  straight,  prominent 
forehead;  the  small  face  ;  the  beaded  ribs  ;  the  deformed 
chest ;  the  tumid  belly  ;  the  twisted,  distorted  limbs  ;  the 
immobility  and  quiet  of  the  little  creature  as  he  sits — if 
he  can  sit — with  bowed  spine  and  head  thrown  back, 
gazing  around  him  with  vacant  eyes  ;  all  these  character- 
istic symptoms  leave  no  room  for  doubt  as  to  the  nature 
of  the  disease. 


DIAGNOSIS 


157 


It  is  only  when  the  disorder  is  at  its  very  commence- 
ment, or  appears  first  about  the  end  of  the  second  year, 
that  it.  is  liable  to  be  overlooked.  A  mild  form  of  rickets, 
consisting  merely  in  a  little  enlargement  of  the  wrists  and 
ankles,  slight  beading  of  the  ribs,  arrested  or  late  denti- 
tion, and  a  large  fontanelle,  is  exceedingly  common,  even 
in  wealthy  families.  The  parents  from  these  signs  alone 
never  suspect  disease,  and  indeed  the  plumpness  of  the 
child,  which  is  often  very  considerable,  is  the  subject  of 
much  admiration.  The  absence  of  teeth  is  looked  upon 
as  an  innocent  peculiarity,  and  cases  are  quoted  of  rela- 
tions, male  and  female,  in  whom  the  same  tardy  dentition 
was  observed.  It  is  not  until  some  complication  arises, 
or  the  disease  enters  a  new  phase,  that  anything  is  noticed 
to  excite  alarm.  But  late  cutting  of  the  teeth  is  seldom 
a  natural  condition.  In  most  cases  of  retarded  dentition 
the  symptoms  of  rickets  may  be  noticed,  and  if  the  tenth 
month  passes  away  without  the  appearance  of  a  tooth, 
suspicions  of  the  disease  should  always  be  excited. 

Lateness  in  walking  attracts  the  attention  of  parents 
much  more  frequently  than  tardy  dentition ;  and  children 
are  often  brought  for  advice  on  account  of  "weakness  in 
the  legs."  In  these  cases,  owing  to  the  inability  of  the 
child  to  support  himself,  even  for  a  moment,  when  held 
upon  his  feet,  essential  paralysis  may  be  suspected.  An 
examination,  however,  will  show  that  although  there  is 
no  power  of  standing,  yet  power  of  movement  is  by  no 
means  lost.  The  child  draws  up  the  legs  when  the  soles 
of  the  feet  are  tickled,  and  the  muscles,  although  weak, 
are  not  absolutely  powerless.  Other  symptoms  of  rickets 
are  also  present. 

When  the  want  of  muscular  power  has  increased  to  sxfili 
a  degree  that  the  child  is  incapable  of  movement,  the 
incapacity  is  general,  and  is  not  confined  to  one  or  more 
limbs.  Moreover,  at  this  stage  the  deformities  of  bone  are 
usually  well  marked,  and  the  chest  distortion  is  very  great. 


158 


RICKETS 


Eelaxation  of  the  ligaments,  and  consequent  unnatural 
mobility  of  the  joints,  is  almost  always  due  to  rickets. 
It  is  a  common  result  when  the  disease  occurs  after  the 
end  of  the  second  year,  and  may  be  present  although 
there  is  no  osseous  deformity,  and  very  little  enlarge- 
ment of  the  ends  of  the  bones.  All  the  articulations 
are  affected,  but  the  knees  and  ankles  seem  to  suffer 
most,  as  they  bear  the  weight  of  the  body.  The  yield- 
ing of  the  ligaments  of  these  joints  may  be  so  great  as  to 
make  walking  difficult  or  even  impossible ;  but  where 
the  relaxation  is  extreme  there  is  usually  combined  with  it 
more  or  less  softening  and  distortion  of  the  bones. 

In  rickety  children,  before  cutting  for  stone,  the  size  of 
the  pelvis  should  be  carefully  studied,  for  narrowness  of 
the  outlet  may  create  great  difficulty  in  removing  the 
calculus.  By  noting  the  degree  of  stunting  and  distortion 
of  the  lower  limbs,  a  fair  guess  may  be  made  as  to  the 
degree  to  which  the  pelvis  is  likely  to  have  suffered  from 
arrest  of  development  and  softening  of  its  bones.  An 
examination  |jer  amim  will,  however,  at  once  remove  any 
doubts :  by  the  finger  introduced  into  the  rectum  we  can 
readily  explore  the  entire  pelvic  cavity,  and  the  size  and 
capacity  both  of  the  brim  and  of  the  outlet  can  by  this 
means  be  satisfactorily  ascertained. 

There  is  one  complication  of  rickets  which  it  is  very 
important  to  recognize  early.  This  is  scurvy.  Spongi- 
ness  of  the  gums,  or  any  unusual  tenderness  of  the  limbs, 
should  at  once  attract  attention.  In  cases  of  advanced 
rickets  there  is  almost  always  a  certain  amount  of  ten- 
derness; but  if  this  symptom  be  present  in  an  extreme 
degree,  or  be  noticed  in  cases  where  the  bone  changes 
ann  trifling  and  the  general  features  of  the  disease  little 
pronounced,  it  should  at  once  suggest  scurvy.  Again, 
symmetrical  local  swelling  of  limbs,  unaccompanied  by 
fluctuation  or  redness  of  the  skin,  is  a  very  suspicious  sign, 
and  one  which  should  always  make  us  examine  the  gums 


PROGNOSIS 


159 


and  inquire  into  tlie  feeding  and  general  management  of 
the  patient. 

In  cases  where  the  scorbutic  phenomena  are  very 
severe,  and  separation  of  epiphyses  has  occurred  with 
symptoms  of  pseudo-paralysis,  the  case  is  distinguished 
from  one  of  inherited  syphilis  by  the  absence  of  other 
signs  of  that  diathetic  disease. 

Prognosis, — The  danger  of  rickets  lies  principally  in  the 
complications.  As  long  as  the  disease  remains  simple,  and 
the  bone- softening  is  not  extreme,  the  prognosis  is  very 
favourable. 

In  estimating  the  danger  of  any  particular  case,  atten- 
tion should  always  be  paid  to  two  points : 
The  amount  of  chest  distortion. 

The  presence  or  absence  of  disease  of  the  spleen,  and 
glandular  system  generally. 
If  the  chest  be  much  distorted,  and  the  softening  of  the 
ribs  great,  there  is  always  cause  for  anxiety.  Owing  to 
the  difficulty  of  respiration  in  these  cases,  there  is  defi- 
cient aeration  of  the  blood  (shown  by  the  lividity  of  the 
lower  eyelid  and  of  the  mouth),  and  consequent  deficient 
oxidation  and  removal  of  waste  matter.  The  slightest 
catarrh,  as  has  been  before  explained  (see  p.  139),  adds  a 
further  obstacle  to  due  aeration ;  and  catarrhs  are  always 
liable  to  occur,  however  carefully  chills  may  be  guarded 
against,  owing  to  the  extreme  sensitiveness  of  a  rickety 
child  to  changes  of  temperature.  Under  such  circum- 
stances the  patient's  life  is  always  in  danger,  for  a  slight 
cold,  which  in  a  healthy  child  would  be  scarcely  worth 
notice,  or  which  would  be  easily  treated  by  domestic 
remedies,  will  be  sufficient  in  a  rickety  child  to  cause 
fatal  collapse  of  the  lungs.  If  a  child,  the  subject  of  this 
disease,  begins  to  cough,  no  prognosis  should  be  h 
until  the  movements  of  the  chest  during  resiDira 
been  carefully  watched  ;  and  here  more  useful  in 
can  often  be  gained  by  the  eye  than  by  the 


160 


RICKETS 


The  danger  is  in  direct  proportion  to  tlie  degree  of  reces- 
sion of  the  ribs  during  inspiration. 

Disease  of  the  spleen  and  other  internal  organs  does 
not  add  to  the  gravity  of  the  prognosis  so  much  as  might 
be  exj^ected.  'No  doubt  the  child  is  less  likely  to  recover 
his  health  than  if  these  organs  were  perfectly  normal ;  but 
cases  where  the  spleen  is  enlarged  do  not  necessarily  end 
fatally.    On  the  contrary,  such  children  often  do  well. 

On  account  of  the  danger  of  catarrh,  disorders  in  which 
this  derangement  is  a  prominent  symptom  are  of  course 
especially  formidable  to  rickety  children.  For  this  reason 
measles  and  whooping-cough  are  to  be  dreaded. 

Of  the  other  complications,  diarrhoea  is  the  most 
serious.  Convulsions  are  very  common,  but  are  usually 
harmless.  Sometimes  laryngismus  stridulus  causes  death. 
The  combination  of  moderate  hydrocephalus  with  rickets 
is  seldom  attended  with  danger. 

Scurvy  is  a  more  serious  complication ;  but  if  recog- 
nised early  and  treated  promptly  with  antiscorbutic  reme- 
dies and  appropriate  diet,  the  symptoms  in  most  cases  will 
quickly  disappear. 

No  indication  for  prognosis  can  be  derived  from  the  age 
of  the  child.  A  slight  degree  of  rickets  is  very  common  in 
infants  of  seven  months  old,  and,  when  the  causes  which 
produced  it  are  removed,  it  ceases  as  readily  in  them  as  in 
older  children.  The  severity  of  the  disease  depends  upon 
the  intensity  and  the  continuance  of  the  causes  of  which 
it  is  the  result. 

Causes. — Rickets  is  a  general  disease,  for  it  affects  the 
tissues  of  the  body  very  widely  ;  but  it  cannot  be  included 
in  the  same  class  of  maladies  with  acute  tuberculosis, 
scrofula,  and  syphilis.  The  latter,  which  are  often  called 
thetic  diseases,  have  special  peculiarities  which 
them  very  distinctly  from  a  disease  of  pure  mal- 
uch  as  rickets.  A  diathesis  has  been  defined 
iracter  of  the  constitution  which  tends  to  the 


CAUSATION 


161 


repeated  expression  of  some  form  of  ill-health,  always  in 
the  same  way.""^  In  other  words,  it  is  a  constitutional 
predisposition  to  repeated  manifestations  of  a  certain  in- 
variable form  of  disease.  Now,  in  rickets,  there  is,  strictly 
speaking,  no  constitutional  predisposition.  It  is  the  result 
of  certain  known  causes,  without  which  the  disease  cannot 
be  produced,  but  under  the  influence  of  which  any  child 
whatever  (with  certain  exceptions,  to  be  afterwards  noticed) 
will  become  rickety.  That  the  disease  occurs  amongst  the 
children  of  the  rich  as  well  as  amongst  the  poor  is  no 
argument  against  this  view,  for  wealth  cannot  buy  judge- 
ment, and  education  is  no  guarantee  against  foolish  indul- 
gence. We  know  that  a  child  may  be  in  reality  starving, 
although  fed  every  day  upon  the  richest  food,  for  he  is 
nourished,  not  in  proportion  to  the  nutritive  properties  of 
the  food  he  swallows,  but  in  proportion  to  his  ability  to 
digest  what  is  given  to  him.  If,  therefore,  he  be  supplied 
with  food  which  is  unsuited  to  his  age,  the  result  is  the 
same,  whether  he  live  in  a  palace  or  a  cottage. 

Cases  occasionally  occur  where  the  mother,  exhausted 
by  chronic  disease,  or  other  depressing  cause,  bears 
children  feeble  at  their  birth,  and  who  very  rapidly  become 
rickety.  But  these  are  not  true  cases  of  constitutional 
predisposition.  The  child  is  born  suffering  already  from 
the  effects  of  deficient  nutrition  in  the  womb.  He  is  then 
at  once  suckled  with  poor  watery  milk,  or  is  brought  up 
by  hand  and  stuffed  with  all  the  hurtful  trash  with  which 
the  ignorance  of  mothers  prompts  them  to  supply  the 
deficiencies  of  their  milk.  The  natural  result  of  such  im- 
perfect nourishment  follows,  and  rickets  declares  itself. 
But  here  the  child  can  only  be  said  to  have  been  pre- 
disposed to  rickets  in  the  sense  that  he  was  born  suffer- 
ing from  a  condition  of  which  rickets  is  the  final  and 
most  striking  stage.    Rickets  does  not  produce  malnutri- 

*  *  Science  and  Practice  of  Medicine,'  by  W.  Aitken,  M.D.,  Edin- 
burgh, 2nd  edition,  1863. 

11 


162 


RICKETS 


tion,  but  malnutrition  produces  rickets.  The  infant  is 
not  born  weakly  because  be  bas  a  rickety  predisposition, 
but  he  falls  a  victim  to  rickets  because  he  was  born 
weakly. 

Moreover,  for  the  full  development  of  the  disease,  it  is 
essential  that  the  same  causes  by  which  nutrition  was 
first  rendered  defective  should  continue  in  operation.  If 
measures  are  taken  to  improve  nutrition,  this  result  does 
not  follow,  for  when  well  cared  for,  and  supplied  with 
proper  nourishment,  the  child  in  all  cases  becomes  strong 
and  healthy.  Rickets  is  not  a  disease  which  must  run  its 
course.  By  judicious  treatment  it  may  be  stayed  at  any 
point  of  its  career ;  and  the  treatment  required  is  merely 
food — food  which  nourishes,  and  drugs  which  are  not  so 
much  medicines  as  food  under  another  name. 

Again,  in  the  true  diathetic  diseases  of  childhood,  here- 
ditary tendency  plays  a  very  important  part,  but  in  the 
case  of  rickets  there  is  very  little  evidence  of  such  a 
cause.  Out  of  the  thousands  of  rickety  children  there 
will  no  doubt  be  many,  one  or  the  other  of  whose  parents 
was  rickety  before  them  ;  but  the  same  thing  may  be 
said  of  any  other  common  disorder.  It  is  always  difficult 
where  many  conditions  unite  in  the  causation  of  a  disease 
to  separate  the  share  which  hereditary  tendency  takes  in 
its  production,  but  no  special  facts  have  yet  been  brought 
forward  to  show  that  rickety  parents  are  more  likely  to 
have  rickety  children  than  parents  who  have  been  alto- 
gether free  from  the  disease — the  other  conditions  re- 
maining the  same. 

Rickets,  then,  is  not  a  diathetic  disease  in  the  sense  in 
which  tuberculosis  and  syphilis  are  diathetic  diseases. 
Before  the  alterations  in  structure  actually  occur  there  is 
nothing  in  the  appearance  of  the  child  to  indicate  the 
disease  from  which  he  is  about  to  suffer.  It  is  acquired 
under  the  influence  of  certain  causes,  lasts  as  long  as 
those  causes  continue  in  operation,  and,  unless  the  struc- 


CAUSATION 


163 


tural  changes  are  so  extensive,  and  the  general  strength  so 
reduced,  as  to  forbid  recovery,  passes  off  when  the  causes 
are  removed. 

These  causes  must  be  looked  for  in  all  those  conditions 
which  interfere  with  the  proper  nutrition  of  the  child. 
Ill-health  or  weak  constitution  of  the  mother  affecting  the 
nutrition  of  the  foetus  in  utero,  and  after  birth  of  the  child 
deteriorating  the  quality  of  the  breast-milk ;  improper 
feeding  generally  ;  ill- ventilated  rooms,  damp,  cold,  dirt, 
want  of  sunlight,  want  of  exercise.  The  continued  in- 
fluence of  these  causes  will  produce  the  disease,  or  rather, 
will  produce  that  unhealthy  condition  of  the  body  of  which 
rickets  is  the  direct  consequence.  The  preliminary  stage, 
that  which  marks  the  beginning  and  progress  of  malnutri- 
tion, and  in  which  the  strength  is  being  gradually  reduced 
to  the  point  at  which  rickets  begins,  may  be  long  or  short 
according  to  the  degree  of  vigour  of  the  child,  and  the 
degree  of  intensity  with  which  the  causes  operate,  or  may 
even  be  absent  altogether.  Its  place  may  be  taken  by  any 
disease  which  interferes  seriously  with  the  assimilative 
power,  and  causes  sufficient  impairment  of  the  general 
strength.  We  thus  get  another  set  of  causes,  which  may 
either  act  independently  of  the  others,  or  may  most  power- 
fully intensify  their  influence.  Thus  rapidly  recurring 
attacks  of  diarrhoea,  chronic  vomiting,  measles,  bron- 
chitis, broncho-pneumonia,  in  fact,  all  the  exhausting 
diseases,  may  have  this  effect. 

Too  early  weaning  is  sometimes  stated  to  be  a  special 
cause  of  the  disease.  It  is  no  doubt  true  that  to  deprive 
a  young  child  of  breast  milk  which  he  can  digest,  and  to 
supply  him  instead  with  food  which  he  cannot  digest,  is 
certain  to  be  hurtful.  In  England,  however,  the  tendency 
is  rather  to  keep  the  child  too  long  at  the  breast,  to 
accustom  him  to  look  to  that  for  his  sole  nourishment 
after  the  time  when  some  additional  food  is  required.  In 
either  case  the  supply  of  nutritive  material  is  equally 


164 


RICKETS 


deficient,  and  the  effect  upon  the  health  of  the  child  must 
be  equally  unfavourable. 

The  connection  between  syphilis  and  rickets  is  interest- 
ing. By  some  writers  great  importance  is  attributed  to 
the  influence  of  the  former  disease  as  a  cause  of  rickets  ; 
indeed,  the  late  M.  Parrot  ventured  so  far  as  to  declare 
that  rickets  was  invariably  the  consequence  of  a  hereditary 
syphilitic  taint.  The  reasons  for  his  belief  adduced  by 
this  distinguished  observer  were  founded  principally  upon 
morbid  anatomy,  especially  upon  a  certain  similarity  of 
lesion  noticed  in  the  epiphysial  ends  of  the  long  bones  in 
the  two  diseases.  There  is  no  doubt  that  rickets  often 
occurs  in  children  the  subjects  of  hereditary  syphilis,  just 
as  it  may  arise  in  any  case  where  the  patient  is  enfeebled 
by  mismanagement  or  disease ;  but  the  clinical  history  of 
the  two  maladies  is  so  different  that  in  this  country,  at 
least,  M.  Parrot's  doctrine  has  met  with  little  acceptance. 

With  regard  to  the  influence  of  tubercle,  rickety 
children,  like  the  subjects  of  any  other  chronic  disease, 
may  fall  victims  to  secondary  acute  tuberculosis ;  and  a 
phthisical  mother  may  bear  rickety  children ;  but  a  child 
in  whom  the  tubercular  diathesis  is  marked  seldom,  if 
ever,  becomes  rickety.  It  is  also  rare  to  find  a  case  of 
rickets  occurring  in  a  family  other  children  of  which  are 
the  subjects  of  tuberculosis. 

Prevention. — If  any  of  the  former  children  of  the  family 
have  been  rickety,  especial  attention  must  be  paid  to  the 
diet  and  general  management  of  the  new-born  babe.  The 
mother  may  still  suckle  the  infant  during  the  first  month, 
but  after  that  time  she  should  give  up  all  idea  of  rearing 
the  child  from  her  own  breast,  and  a  wet  nurse  should  be 
provided.  If  from  circumstances  this  is  impossible,  the 
breast-milk  must  be  limited  to  two  meals  a  day ;  the  child 
being  fed  at  other  times  upon  cow's  milk  and  barley-water, 
or  any  other  suitable  diet,  as  recommended  in  an  earlier 
part  of  this  volume.    At  the  same  time,  all  the  other  pre- 


TREATMENT 


165 


cautions  so  essential  to  perfect  health  must  be  carefully 
observed.  Perfect  cleanliness,  warm  clothing,  fresh  air, 
well- ventilated  rooms,  sunlight,  are  all  indispensable.  If 
the  parents  reside  in  a  cold  damp  situation,  the  child 
should,  if  possible,  be  removed  to  a  neighbourhood  where 
the  quality  of  the  air  is  drier  and  more  bracing.  For  full 
particulars  as  to  the  best  method  of  preventing  the  occur- 
rence of  rickets  the  reader  is  referred  to  the  section  on  the 
treatment  of  simple  atrophy,  where  rules  are  laid  down  for 
the  healthy  feeding  and  management  of  young  children. 

Treatment. — In  the  treatment  of  rickets,  our  first  care 
must  be  to  endeavour  to  restore  healthy  nutrition.  This 
can  only  be  done  by  attention  to  diet  and  to  general 
hygiene,  taking  care  at  the  same  time  to  correct  any 
disordered  condition  of  the  alimentary  canal  which  may 
be  present  to  interfere  with  the  proper  digestion  and 
assimilation  of  the  food  supplied.  This  is  indispensable 
as  a  first  step,  for  to  give  tonics  while  the  causes  which 
have  produced  the  disease,  and  sustain  it,  continue  in 
operation,  is  a  course  which  cannot  possibly  be  attended 
with  any  good  result. 

In  almost  all  cases  the  bowels  will  be  found  to  be  rather 
relaxed,  two  or  three  stools  being  passed  in  the  course  of 
the  day,  consisting  of  offensive,  putty-like  matter,  mixed 
largely  with  mucus,  often  greenish,  and  occasionally 
streaked  with  blood  from  the  straining  efforts  with  which 
they  are  evacuated.  The  foetor  is  due  to  decomposition 
of  the  undigested  food.  It  is  best  to  begin  the  treatment 
with  a  gentle  laxative,  such  as  a  teaspoonful  of  castor  oil, 
or  a  small  dose  of  rhubarb  and  soda.  The  bowels  having 
been  thus  relieved,  alkalies  should  be  given,  with  a  little 
opium,  in  some  aromatic  water.  The  following  prescrip- 
tion is  useful  in  these  cases,  or  some  of  the  medicines 
ordered  for  a  similar  condition  of  the  bowels  in  the  treat- 
ment of  simple  atrophy  may  be  adopted  : — 


166 


RICKETS 


Tinct.  Opii,  irvj, 
Sodte  Bicarb.,  gr.  iv, 
Sp.  Ammon.  Aromat., 
Sp.  Clilorof.,  mj, 
Aq.  Cinnamomi  ad  5ij. 
To  be  taken  three  times  a  day. 

The  opium  is  of  great  use  in  diminishing  the  abnormal 
briskness  of  the  peristaltic  action  of  the  bowels,  and 
should  never  be  omitted  from  the  mixture  so  long  as  the 
stools  present  the  appearances  which  have  been  described. 
Under  such  or  similar  treatment  the  motions  will  be 
found  in  a  few  days  to  assume  a  more  healthy  character ; 
griping,  if  previously  present,  will  be  diminished,  or  will 
have  altogether  ceased ;  and  the  general  condition  of  the 
patient  will  be  much  improved.  At  the  same  time  the 
diet  of  the  child  must  be  regulated  to  suit  the  degree  of 
debility  to  which  he  may  be  reduced,  remembering  that 
the  greater  his  weakness,  the  more  nearly  does  his  diges- 
tive power  resemble  in  degree  that  of  a  new-born  infant. 
Full  directions  about  diet  have  already  been  given  in  a 
former  chapter  (see  Treatment  of  Simple  Atrophy),  and 
need  not  here  be  repeated.  It  may,  however,  be  remarked 
that  it  will  usually  be  found  necessary  very  greatly  to 
reduce  the  quantity  of  farinaceous  matter  which  is  being 
taken.  Under  the  mistaken  notion  that  such  food  is 
especially  nutritious  and  easy  of  digestion,  weakly  chil- 
dren, whatever  their  age  may  be,  are  commonly  made 
to  depend  for  their  support  chiefly  upon  sago,  arrowroot, 
tai:)ioca,  and  similar  articles  of  diet.  The  amount  of  this 
food  must  be  therefore  considerably  restricted,  according 
to  the  rules  already  laid  down,  and  its  place  should  be 
supi^lied  by  milk,  gravy,  strong  beef -tea,  minced  meat 
once  cooked,  yolks  of  eggs  lightly  boiled,  &c.,  according 
to  the  age  and  strength  of  the  child. 

Plenty  of  fresh  air  is  indispensable  to  the  successful 

*  See  Chap.  XI,  Diets  5,  6,  7,  8,  10,  11,  and  18. 


PROTECTION  FROM  CHILLS  167 

treatment  of  rickets.  The  child  should  be  taken  out 
regularly  into  the  open  air,  and  as  he  gets  gradually 
stronger  should  pass  more  and  more  of  his  time  out  of 
doors.  The  quality  of  the  air  is  of  much  importance,  and 
sea- side  places,  where  the  air  is  dry  and  bracing,  as 
Westgate,  Scarborough,  Brighton,  and  Eastbourne,  are 
especially  to  be  recommended.  Rickety  children  are  often 
kept  confined  to  the  house  during  the  winter  months  on 
account  of  their  tendency  to  chills,  and  it  may  be  objected 
to  the  medical  practitioner  that  whenever  the  child  goes 
out  he  catches  cold."  In  these  cases  it  will  be  usually 
found  on  examination  that  the  child's  feet  are  habitually 
cold.  If  care  be  taken  that  the  feet  are  thoroughly  warm 
before  the  child  leaves  the  house,  and  if  at  the  same  time 
the  body  and  limbs  are  warmly  wrapped  up,  the  patient 
may  be  sent  out  of  doors,  all  through  the  cold  season,  not 
only  without  danger,  but  with  the  greatest  possible 
benefit  to  his  health.  In  every  case  of  rickets  the  belly 
should  be  kept  covered  with  a  flannel  bandage  ^  during 
the  day,  and  the  child  should  wear  next  his  skin  a  flannel 
or  pure  woollen  combination  "  garment.  Stockings  to 
reach  up  above  the  knee  are  to  be  preferred  to  short  socks. 

It  is  more  often  within  the  house  than  without  that  the 
child  takes  cold.  Not  seldom  it  is  in  the  night  that  the 
chill  occurs.  While  asleep  in  his  bed  the  patient  sweats 
profusely.  Inconvenienced  by  the  heat  he  kicks  off  the 
bed  coverings  and  throws  his  bare  legs  on  to  the  counter- 
pane. As  he  lies  thus  exposed,  his  naked,  perspiring  body 
is  as  wet  as  if  it  had  been  dipped  in  water,  and  the  evapo- 
ration which  takes  place  chills  the  surface  sufficiently  to 
induce  a  very  decided  catarrh.  I  have  known  many  an 
instance  in  which  obstinate  diarrhoea  in  a  rickety  subject 
has  been  kept  up  by  this  means.    It  is  advisable,  there- 

*  The  abdominal  bandage  has  another  use  in  retarding  the  too 
rapid  descent  of  the  diaphragm.  This,  when  the  bones  are  much 
softened,  affords  great  relief. 


168 


RICKETS 


fore,  in  all  cases  where  a  rickety  child  is  subject  to  frequent 
and  mysterious  catarrhs,  to  make  inquiry  into  this  matter, 
and  to  take  measures  to  prevent  the  child  uncovering  his 
body  in  his  sleep.  Infants  should  be  put  into  a  loose 
flannel  bag  which  can  be  tied  under  the  arm-pits.  In  this 
they  can  kick  about  their  limbs  without  risk  of  exposure. 
Older  children  may  wear  woollen  "  combinations."  When 
these  precautions  are  taken,  the  bed  coverings  must  be 
light.    More  than  one  blanket  will  seldom  be  required. 

The  copious  perspirations  to  which  these  children  are 
subject  when  asleep  make  it  necessary  to  see  that  the 
bedding  and  sheets  are  not  allowed  to  remain  damp.  The 
sheets  must  be  dried  carefully  before  the  fire  and  not 
merely  exposed  to  the  air.  I  have  known  a  gastro-intes- 
tinal  catarrh  to  be  maintained  for  weeks  together  for  want 
of  this  simple  precaution.  On  account  of  the  free  action 
of  the  skin  it  is  important  to  attend  to  cleanliness  ;  but 
the  washing  bath  must  be  conducted  briskly  lest  the 
child  catch  cold.  It  is  best  to  sponge  him  quickly 
in  a  bath  of  hot  soap-suds.  In  this  way  the  long — and  to 
a  sensitive  baby  dangerous — soaping  process  is  avoided. 
When  taken  from  the  bath  he  must  be  wrapped  up  in  a 
large  warm  towel  and  dried  with  as  little  exposure  as 
possible.  The  bath  should  be  given  at  night.  The 
ventilation  of  the  nurseries  must  be  attended  to,  and  in 
warm  weather  a  lamp  placed  in  the  fender  is  useful  to 
promote  a  free  current  of  air. 

The  influence  of  the  preceding  measures  is  usually  most 
marked,  and  it  is  at  this  time  that  tonic  medicines  are  so 
valuable.  They  ought  not,  however,  to  be  given  until,  by 
suitable  treatment,  the  motions  have  become  healthy  and 
the  tongue  clean. 

Iron  is  one  of  the  most  important  medicines  we  have  at 
our  disposal.  A  good  form  for  its  administration  is  the 
following  : — 


DRUGS 


169 


^    Liq.  Ferri  Pernitratis, 

Acidi  Nitrici  diluti,  aa  tnj, 
Glycerini,  mv, 

Infusum  Caluinba3  ad  5ij.    M.    Ft.  haustus. 
To  be  taken  directly  after  food,  three  times  a  day. 

If  the  debility  is  very  great,  the  ammonio- citrate  may  be 
given  with  sal  volatile — 

Ferri  et  Ammonia3  Citratis,  gr.  ij. 
Spirit.  Ammoniac  aromat., 
Sp.  Chloroformi,  aa  mij, 
Infusum  Ci^lumbse  ad  5ij.    M.    Ft.  haustus. 
To  be  taken  one  hour  before  food  three  times  a  day. 

Or  the  tincture  of  the  perchloride  may  be  combined  with 
dilute  hydrochloric  acid  and  spirits  of  chloroform  in  the 
same  infusion. 

Chalybeate  waters,  such  as  those  of  Tunbridge  Wells, 
are  of  service. 

Quinine  ^  is  very  useful.  It  may  be  given  either  with 
dilute  nitric  acid  or  in  the  form  of  the  double  citrate  of 
iron  and  quinine. 

Tannin  is  recommended  by  Dr.  Alison.  It  may  be  given 
in  doses  of  from  half  a  grain  to  a  grain,  two  or  three 
times  a  day,  in  a  little  dilute  nitric  acid.  The  author 
has  seen  very  marked  improvement  follow  the  use  of  this 
drug. 

The  remedy,  however,  which  justly  takes  the  highest 
rank  in  the  treatment  of  rickets  is  cod-liver  oil.  The 
influence  of  this  drug  in  improving  general  nutrition  is 
seen  almost  immediately  :  and  when  given  under  favour- 
able conditions — in  cases,  that  is,  where  the  deficient 

*  Quinine  is  best  given  to  young  children  in  milk.  Mr.  Batterbury 
has  pointed  out  that  milk  not  only  dissolves  quinine,  but  also  to  a 
great  extent  disguises  its  bitterness.  It  has  been  suggested  that  the 
drug  should  be  prescribed  suspended  in  glycerine  (one  grain  to  the 
drachm),  and  that  the  nurse  should  be  directed  to  administer  the  dose 
in  a  wineglassf  ul  of  milk. 


170 


RICKETS 


sanitary  arrangements  which  originated  the  disease  have 
been  corrected — the  rapid  change  for  the  better  in  the 
general  condition  of  the  patient,  and  the  quickness  with 
which  the  more  pressing  symptoms  disappear,  will  often 
be  a  matter  of  surprise. 

The  oil  may  be  administered  in  a  tonic  mixture,  but  it 
must  not  be  given  at  first  in  too  large  doses.  To  begin 
with,  ten  to  fifteen  drops  may  be  poured  into  each  dose 
of  the  medicine,  and  the  quantity  can  be  gradually 
increased  to  a  teaspoonful.  Cod-liver  oil  may  be  usefully 
combined  with  iron,  as  in  the  following  mixture  : — 

1^    Ferri  et  Ammonise  Citratis,  gr.  ij, 
Tinct.  Calumbse,  mv, 
Olei  Morrhuae,  rrtx, 
Aq.  Calcis  ad  5j.    M.    Ffc.  liaustus. 
To  be  taken  after  food,  three  times  a  day. 

During  the  administration  of  the  oil  the  stools  should  be 
examined  from  time  to  time.  Any  smell  in  them  of  the 
oil  is  a  sure  sign  that  more  is  being  given  than  can  be 
digested,  and  the  quantity  must  be  reduced. 

With  regard  to  the  bone  deformities  : — If  the  tibiae  are 
much  bowed  the  child  should  be  prevented  as  much  as 
possible  from  walking  until  reconsolidation  of  the  bones 
has  sufficiently  advanced.  Careful  watching,  however,  is 
required  to  prevent  his  getting  upon  his  feet,  for  as  his 
strength  improves  his  delight  in  his  newly-acquired 
powers  is  prodigious,  and  he  seems  anxious  by  incessant 
activity  to  make  up  for  his  previously  enforced  quiet. 
Light  carefully  padded  splints  should  be  aj^plied  to  the 
legs,  and  it  is  advisable  that  the  supports  should  project 
below  the  feet,  so  as  to  render  it  impossible  for  the 
patient  to  stand.  In  recent  cases,  where  the  tibise  are 
bowed  forwards,  or  forwards  and  outwards,  the  plan  may 
be  adopted  of  forcibly  straightening  the  bones,  and  then 
applying  splints.  This  is  done  without  difficulty  in 
children  under  two  years  of  age.    If  the  bone  should 


TREATMENT  OF  COMPLICATIONS 


171 


even  snap  in  the  operation  the  accident  does  not  interfere 
with  the  process  of  cure,  for  union  readily  takes  place.  It 
must  be  remembered  that  this  plan  is  only  applicable  to 
cases  where  the  deformity  has  been  rapidly  developed  and 
is  still  recent. 

When  the  tenderness  has  subsided,  the  spine,  and  back 
generally  are  much  strengthened  by  careful  shampooing. 
Each  morning,  after  his  bath,  the  child  should  be  laid 
upon  his  face  on  the  bed,  and  the  whole  back  should  be 
well  and  firmly  rubbed  with  the  open  hand  from  the  neck 
to  the  buttocks.  The  frictions  should  be  continued  for 
about  ten  minutes.  In  the  evening  the  same  process  may 
be  repeated  before  the  child  is  put  to  bed. 

In  cases  where  the  ligaments  of  the  joints  are  very  weak 
and  relaxed,  a  carefully  applied  elastic  bandage  affords  the 
best  support. 

The  profuse  sweating  from  the  head  can  be  controlled 
by  belladonna,  either  given  internally  or  applied  locally  as 
a  liniment.  If  given  by  the  mouth,  care  must  be  taken  to 
give  a  sufficient  quantity,  remembering  the  great  tolerance 
of  children  for  this  drug.  Five  drops  of  the  tincture  may 
be  given  at  first  three  times  a  day  to  a  child  of  twelve 
months  old,  or  ten  drops  can  be  given  in  one  dose  at 
bedtime.  If  the  sweating  continues  the  quantity  of  bella- 
donna must  be  increased. 

Treatment  of  the  complications. — The  first  symptoms  of 
catarrh  should  always  be  attended  to  at  once,  for  there  is 
no  complication  which  is  so  dangerous  to  rickety  chil- 
dren. 

Prompt  counter  irritation  to  the  chest  should  be  at  once 
adopted,  and  this  is  found  to  be  more  effectual  when  a 
mild  irritant  is  kept  applied  for  a  long  period  to  a  large 
surface  of  the  body.  Thus,  the  chest  may  be  enveloped 
in  a  poultice  containing  one  part  of  mustard  to  five  of 
linseed  meal ;  and  this  application  may  be  kept  in  contact 
with  the  skin  for  a  whole  night  together,  even  in  the  case 


172 


RICKETS 


of  an  infant.  At  the  same  time  a  saline  diaphoretic 
mixture,  such  as  the  following,  should  be  ordered : — 

Vini  Antimonialis,  rav, 
Sp.  ^theris  Nitrosi,  mv, 
Liq.  Ammon.  Acetatis,  rnxv, 
Glycerini,  nv, 
Aq.  Flor.  Aurant.^  ^nx, 
Aq.  ad  5j.    M.    Ft.  haustus. 
To  be  taken  every  four  hours. 

Our  object  is  to  produce  as  rapidly  as  possible  free 
secretion  from  the  bronchial  tubes ;  for  the  tough  mucus 
which  is  first  secreted  lines  the  walls  of  the  air-tubes, 
greatly  diminishing  their  calibre,  and  also  is  apt  to  form 
plugs  which,  driven  farther  and  farther  into  the  tubes,  act 
as  valves,  permitting  egress,  but  forbidding  ingress  of  the 
air.  This  is,  as  has  already  been  explained,  the  cause  of 
the  collapse  so  often  found  after  death  occupying  the 
posterior  and  inferior  parts  of  the  lung.  The  thinner  the 
secretion,  the  smaller  the  liability  to  the  formation  of  these 
plugs,  and  therefore  the  less  the  danger  of  collapse. 

When  the  cough  has  become  quite  loose,  a  few  drops  of 
sal  volatile  may  be  added  to  the  mixture,  and  the  stimu- 
lating expectorants  generally  are  now  admissible. 

If  the  debility  is  very  great,  a  little  wine  or  a  few  drops 
of  pale  brandy  can  be  given  every  few  hours  while  the 
mixture  is  being  taken,  but  no  stimulating  expectorants 
should  be  prescribed  until  the  secretion  is  copious. 

If  there  is  much  rattling  of  mucus  in  the  chest  during 
respiration,  a  teaspoonful  of  vinum  ipecacuanhse  may  be 
given  at  once,  and  be  repeated  every  ten  minutes  until 
vomiting  is  produced.  An  emetic,  by  its  mechanical  action, 
helps  to  clear  the  tubes  of  mucus. 

When  diarrhoea  occurs  it  must  be  checked  as  rapidly 
as  possible,  for  the  exhaustion  it  induces  in  a  child  already 
enfeebled  is  extreme.    The  following  rules  will  be  found 


TREATMENT  OF  DIARRHCEA 


173 


useful  in  these  cases,  and  in  the  acute  diarrhoeas  of  chil- 
dren generally. 

If  the  child  is  seen  early,  a  dose  of  castor  oil,  by  clearing 
away  the  irritant  from  the  bowels,  will  usually  arrest  the 
purging  at  once.  In  any  case,  if  the  tongue  be  furred, 
it  is  best  to  begin  the  treatment  with  a  mild  aperient, 
such  as  castor  oil,  or  rhubarb  and  soda.  Afterwards  the 
treatment  must  vary  according  to  the  character  of  the 
symptoms. 

Thus  if  the  tongue  is  furred  white  or  yellow,  the  skin 
hot,  the  belly  hard,  and  the  motions  green  and  slimy,  with 
much  straining  and  griping  pain,  the  following  mixture 
will  be  of  service  : — 

1^    Tinct.  Opii,  mj, 

Olei  Kicini,  iuiij> 

Mucillaginis  Acacite, 

Glycerini,  aa  irtv, 

Aquam  ad  3ij.  M. 
To  be  taken  three  times  a  day. 

If  the  tongue  is  furred  white  or  yellow,  skin  hot,  the 
belly  soft,  the  motions  pale,  frothy,  and  sour- smelling, 
without  straining,  an  antacid  is  required,  and  a  mixture 
containing  chalk,  catechu,  and  aromatic  confection  may 
be  ordered. 

If  with  a  clean  tongue  the  motions  are  dark,  watery, 
and  stinking,  with  or  without  straining,  the  condition 
must  be  treated  with  opium,  and  astringents  such  as  sul- 
phuric acid  or  tannin. 

If,  in  spite  of  this,  the  diarrhoea  still  goes  on,  the  treat- 
ment recommended  under  the  head  of  chronic  diarrhoea 
must  be  resorted  to.  In  all  these  cases  the  application 
of  a  broad  flannel  bandage  to  the  belly  should  be  insisted 
upon. 

When  either  of  these  complications  (diarrhoea  or  catarrh) 
is  present,  the  diet  must  be  at  once  altered  to  suit  the 
temporarily  reduced  power  of  digestion. 


174 


RICKETS 


In  the  case  of  convulsions  and  laryngismus  stridulus  the 
tendency  to  these  nervous  seizures  is  counteracted  by  the 
measures  recommended  for  the  general  treatment  of  the 
rickety  constitution.  In  proportion  as  nutrition  becomes 
restored  the  proneness  to  convulsions  also  disappears. 

When  called  to  a  child  suffering  from  a  convulsive 
attack,  we  should  at  once  give  orders  for  the  preparation 
of  a  warm  bath  (90°  Fah.).  While  this  is  being  done  we 
can  search  for  some  local  cause  capable  of  explaining  the 
nervous  commotion.  Scybalous  lumps  in  the  bowel  should 
be  removed  by  a  copious  enema ;  irritation  of  the  stomach 
must  be  relieved  by  a  spoonful  of  ipecacuanha  wine ;  a 
tense  swollen  gum  requires  the  use  of  the  gum-lancet ; 
and  signs  of  pain  and  tenderness  about  the  ear  suggest 
the  employment  of  hot  fomentations.  If  the  tympanum 
be  unquestionably  inflamed,  the  aural  meatus  can  be 
plugged  with  cotton-wool,  while  a  leech  is  applied  to  the 
concha. 

A  young  child  should  not  be  kept  for  more  than  ten 
minutes  in  the  warm  water*  Afterwards,  if  the  fits  con- 
tinue in  spite  of  treatment,  prompt  measures  must  be 
taken  to  subdue  the  excitement  of  the  nervous  system. 
One  of  the  best  remedies  in  these  cases  is  the  nitrite  of 
amyl,  as  recommended  by  Dr.  A.  E.  Bridger.  Whatever 
be  the  cause  of  the  attack,  the  inhalation  of  one  drop  of 
the  nitrite  usually  arrests  it  at  once.  If  preferred,  the 
remedy  may  be  given  by  the  mouth,  and  half  a  drop  for  a 
child  of  twelve  months  old,  suspended  in  glycerine  and 
mucilage,  can  be  administered  every  half  hour  until  the 
convulsions  cease.  Afterwards,  a  dose  every  three  or  four 
hours  will  prevent  any  return  of  the  nervous  troubles. 
The  hypodermic  injection  of  morphia  is  another  useful 
method  of  controlling  the  eclamptic  seizures.  In  this  con- 
dition of  the  nervous  system  there  seems  to  be  a  certain 
tolerance  for  the  narcotic.  For  a  child  of  twelve  months 
old  one  twenty-fourth  of  a  grain  may  be  introduced  under 


TREATMENT  OF  LARYNGISMUS 


175 


the  skin,  and  the  injection  can  be  repeated  every  hour 
until  the  convulsive  movements  are  at  an  end. 

To  prevent  the  recurrence  of  the  fits  bromide  of  potas- 
sium or  ammonium  in  doses  of  four  grains,  or  the  hydrate 
of  chloral  in  doses  of  two  and  a  half  grains,  may  be  given 
three  or  four  times  a  day  to  a  child  of  one  yepor  old. 
Chloral  is  also  useful  during  the  actual  attacks.  If  the 
child  cannot  swallow,  four  or  five  grains  dissolved  in  a 
little  water  can  be  thrown  up  the  rectum. 

Laryngismus  is  quickly  arrested,  as  a  rule,  by  the  chloral 
treatment.  It  is  important  that  this  complication  be  not 
spoken  of  too  lightly,  for  it  sometimes  unexpectedly  proves 
fatal.  The  derangement  may  often  be  cured  at  once  by 
bathing  the  child's  whole  body  two  or  three  times  a  day 
with  water  of  the  temperature  of  60°  Fahr.  It  is  well  to 
remember  that  although  fresh  air  is  of  extreme  importance 
in  these  cases  in  forwarding  the  cure,  the  utmost  care  must 
be  taken  that  the  child  before  leaving  the  house  is  properly 
protected  against  the  cold,  for  a  catarrh  greatly  increases 
the  gravity  of  the  attacks.  If  the  child  be  seen  during  the 
paroxysm,  this  may  be  usually  made  to  cease  immediately 
by  applying  a  bottle  of  ordinary  volatile  smelling-salts  to 
the  patient's  nostrils.  In  very  bad  cases  it  is  important 
to  pass  the  finger  into  the  back  of  the  child's  throat,  so  as 
to  bring  forward  the  tongue,  and  release  the  epiglottis 
should  the  latter  be  incarcerated.  It  must  not  be  for- 
gotten that  laryngeal  spasm  is  often  the  consequence  of 
adenoid  growths.  If  these  vegetations  are  present  they 
should  be  removed  without  delay. 

The  large  size  of  the  head  in  rickety  children  often  gives 
rise  to  a  suspicion  that  the  fits  are  due  to  hydrocephalus, 
and  very  active  treatment  is  resorted  to,  sometimes  with 
disastrous  results.  Kickety  children  cannot  bear  lowering 
measures  at  any  time,  and  to  reduce  the  strength  while 
convulsions  are  actually  present,  is  only  to  increase  the 
number  and  the  intensity  of  the  fits. 


176 


RICKETS 


If  symptoms  of  scurvy  are  noticed,  the  child  should  be 
placed  without  loss  of  time  upon  an  anti- scorbutic  regimen. 
All  tinned  and  preserved  foods  should  be  at  once  discon- 
tinued, and  fresh  milk,  raw  meat-juice  or  pounded  raw 
meat,  and  a  proper  proportion  of  vegetable  should  be 
substituted  for  his  former  unwholesome  diet.  The  flower 
of  broccoli,  young  French  beans,  vegetable  marrows, 
asparagus  heads,  and  Spanish  onion,  if  thoroughly  boiled 
and  afterwards  passed  through  a  fine  sieve,  may  be  given 
safely  to  a  child  of  twelve  months  old.  A  certain  quantity 
of  fresh  fruit  can  be  also  allowed;  and  lemon  juice  is 
usually  well  borne  by  scorbutic  infants.  If  the  strength 
be  much  reduced,  port  wine  or  the  St.  Raphael  tannin 
wine  may  be  given,  diluted  with  water.  For  medicine, 
the  child  should  take  cod's  liver  oil,  and  quinine  dissolved 
in  lemon  juice  and  sweetened  with  syrup ;  or  five  to  ten 
drops  of  the  tincture  of  perchloride  of  iron  well  diluted. 

For  spongy  gums  Dr.  Cheadle  recommends  the  glyce- 
rines of  tannin  and  carbolic  acid  (fifteen  drops  of  each  to 
the  ounce  of  water)  to  be  applied  with  a  brush.  The  child 
should  occupy  well-ventilated  rooms,  and  should  pass 
much  of  his  time  in  the  open  air.  For  local  application 
to  the  limbs  wet  compresses  closely  applied  and  covered 
with  oiled  silk  should  be  made  use  of.  If  the  epiphyses 
have  separated,  splints  will  be  required. 


CHAPTER  V 


INHERITED  SYPHILIS 

INHEEITED  Syphilis,  as  it  attacks  the  infant,  presents 
a  combination  of  the  so-called  secondary  and  tertiary 
stages  of  the  disease,  the  primary  stage  being  absent.  The 
skin  and  mucous  membranes  invariably  exhibit  the  cha- 
racters of  secondary  syphilis,  and  these  external  manifesta- 
tions are  often  combined  with  others  indicating  serious 
lesions  of  the  bones  and  internal  organs.  The  disease  may 
first  show  itself  in  the  child  at  three  different  periods, — 
viz.  before  birth,  at  birth,  or  after  birth. 

If  he/ore  hirth,  it  occurs  usually  from  the  fifth  to  the 
seventh  month  of  intra-uterine  life.  The  child  dies,  and 
is  born  dead  before  the  proper  time.  This  disease  is  so 
common  a  cause  of  miscarriage,  that  when  labour  has 
repeatedly  occurred  prematurely  our  susj)icions  should 
always  be  excited,  and  we  should  make  inquiry  as  to  the 
previous  health  of  the  parents,  so  that  by  the  proper  treat- 
ment of  one  or  both  the  lives  of  succeeding  children  may 
be  preserved. 

If  at  hirthy  the  symptoms  are  usually  very  severe.  The 
child,  although  born  alive,  is  emaciated,  and  looks  shri- 
velled. He  snuffles  and  cries  hoarsely.  A  few  hours  after 
birth,  an  eruption  of  pemphigus  appears,  situated  princi- 
pally on  the  palms  of  the  hands  and  the  soles  of  the  feet. 
The  bullae  become  filled  with  a  semi-purulent  liquid,  and 
burst,  leaving  angry-looking  sores.  Spots  of  inflamma- 
tion, with  abscesses,  are  scattered  through  the  thymus 

12 


178 


INHERITED  SYPHILIS 


gland  and  through  the  lungs.  The  liver  is  indurated. 
The  infant  may  linger  on  for  a  few  days  or  weeks,  bvit 
these  cases  almost  always  prove  fatal. 

Although  appearing  at  birth,  the  symptoms  are  not, 
however,  always  so  marked  as  those  described.  The 
amount  of  flesh  may  be  considerable,  and  the  lesions  of 
the  internal  organs  may  not  be  present.  In  such  cases 
the  child  may  recover,  but  the  prognosis  is  exceedingly 
unfavourable. 

If  after  birth ^  the  child  is  born  apparently  healthy.  He 
is  often  plump,  seems  strong,  and  presents  no  symptoms 
by  which  even  the  most  practised  eye  can  detect  the 
disease  lurking  in  his  system.  Sometimes,  however, 
although  offering  no  distinct  symptoms  of  disease,  there 
is  yet  a  something  which  seems  to  hint  at  the  approach- 
ing outbreak.  The  face  is  rather  old-looking;  the  skin 
inelastic  and  unnaturally  pale  ;  the  complexion  dull  and 
wanting  in  transparence. 

After  a  time,  varying  from  two  weeks  to  six  or  seven 
months,  although  rarely  after  the  end  of  the  third  month, 
evident  symptoms  of  the  disease  begin  to  be  observed. 
Before  this,  however,  there  is  one  symptom  which  has 
been  little  noticed  by  writers  upon  this  subject  as  a  sign 
of  the  inherited  disease,  but  which  is  seldom  absent. 
This  symptom  is  obstinate  wakefulness  at  night.  The 
child  when  put  to  rest  is  uneasy  and  fretful,  he  cries 
almost  unceasingly,  and  cannot  be  pacified.  During  the 
day  he  is  more  composed,  but  every  night  there  is  a 
repetition  of  the  same  disturbance,  and  his  uncontrollable 
complaints  are  a  source  of  the  utmost  perplexity  and 
distress  to  his  attendants.  The  crying  is  possibly  excited 
by  nocturnal  pains  in  the  bones  similar  to  those  affecting 
adults  before  the  outbreak  of  the  constitutional  symptoms. 
On  the  appearance  of  the  rash  the  sleeplessness  does  not 
at  once  subside,  but  it  soon  disappears  under  the  influence 
of  specific  treatment.    The  outbreak  of  the  general  symp- 


SYMPTOMS 


179 


toms  may  be  determined  by  some  febrile  attack,  as  one  of 
the  exanthemata,  the  eruption  of  which  subsiding  leaves 
the  syphilitic  rash  in  its  place.  In  almost  all  cases  one  of 
the  earliest  signs  of  the  disease  is  snuffling.  The  mother 
in  the  beginning  attributes  little  importance  to  this  sym- 
ptom, and  indeed  does  not  usually  mention  it  unless  ques- 
tioned specially  upon  the  point,  when  she  replies  that  the 
child  has  "  had  a  cold  "  for  a  few  days.  Soon  the  mucous 
membrane  lining  the  air-passages  becomes  more  swollen, 
but  even  then  there  is  not  much  snuffling  so  long  as  the 
child  breathes  through  his  mouth.  When,  however,  he 
takes  the  breast,  his  difficulty  of  breathing  through  the 
nose  becomes  at  once  apparent.  Each  inspiration  is 
accompanied  by  a  slight  snore,  and  as  the  obstruction 
becomes  more  decided  he  can  only  suck  at  short  intervals, 
desisting  frequently  and  lying  with  the  nipple  in  his 
half-open  mouth,  so  as  to  obtain  a  supply  of  air  before 
making  another  effort  to  draw  out  the  milk.  Occa- 
sionally he  snorts  violently  as  if  in  an  attempt  to  clear 
away  some  obstruction,  and  this  often  causes  serious 
alarm  to  the  mother,  who  will  complain  that  the  child 
seems  as  if  he  were  going  to  be  suffocated  when  he  takes 
the  breast." 

After  a  time  there  appears  from  the  nostrils  a  slight 
watery  discharge,  which  may  be  tinged  with  blood.  It 
is  seldom  profuse  at  first,  and  is  often  merely  enough  to 
give  a  glistening  appearance  to  the  openings  of  the  nares. 
G-radually,  however,  it  becomes  more  abundant,  and 
acquires  consistence,  so  that  it  forms  crusts  which  block 
up  the  nasal  apertures,  and  still  further  impede  the  pas- 
sage of  the  air.  The  discharge  is  intensely  irritating, 
and  scalds  the  parts  with  which  it  comes  into  contact ; 
producing  cracks  and  little  ulcerations  about  the  nostrils 
and  upper  lip,  which  become  encrusted  with  minute  scabs. 
Diday,  however,  believes  these  external  cracks  and  ulcers 
to  be  due  to  mucous  patches,  and  to  be  independent  of  the 


180 


INHERITED  SYPHILIS 


discharge  :  the  discharge  itself  he  attributes  to  mucous 
patches  developed  on  the  Schneiderian  membrane.  In 
severe  cases  the  ulceration  thus  set  up  within  the  nose 
may  perforate  the  septum  nasi,  or  lay  bare  the  nasal  bones 
which  may  become  necrosed.  Fragments  of  these  bones 
are  sometimes  found  in  the  crusts  thrown  off.  The  bones 
may  also  become  loosened  and  sink  down,  so  that  the 
bridge  of  the  nose  is  flattened,  and  looks  broader.  In  rare 
cases  snuffling  is  the  only  symptom  of  the  disease :  some- 
times, but  very  rarely,  it  is  completely  absent  throughout. 

Soon  after  the  beginning  of  the  coryza,  an  eruption  is 
noticed  on  the  skin.  It  is  usually  first  seen  about  the 
arms  and  perinaeum  in  the  form  of  flattened,  slightly 
elevated  spots,  resembling  very  much  in  their  colour  the 
rust  of  iron,  and  which  with  a  lens  may  be  sometimes 
seen  to  be  covered  on  their  surface  with  minute  scales. 
More  commonly,  however,  no  scales  are  visible,  for  as  soon 
as  formed  they  are  softened  by  the  natural  moisture  of 
the  part  and  become  detached.  These  spots  are  scattered 
over  the  perinseum,  surround  the  anus,  and  speckle  the 
scrotum  or  the  labia.  Sometimes  the  eruption  begins  as 
an  erythematous  blush,  at  first  bright  red,  which  covers 
the  buttocks  and  perinseum,  and  may  extend  to  the  lower 
part  of  the  belly.  The  colour  soon  gets  more  dingy,  and 
has  been  aptly  compared  to  the  lean  of  ham.  It  becomes 
at  the  same  time  distinctly  circumscribed,  ending  at  its 
boundaries  in  an  abrupt  line.  The  coloured  surface  is 
scaly,  and  at  its  edges  are  seen  the  rust- coloured  spots 
before  described.  The  eruption  is  not  limited  to  these 
parts ;  it  often  invades  the  folds  of  the  joints,  particularly 
the  armpits,  extends  to  the  sides  of  the  neck  or  the  chin, 
and  may  be  sprinkled  all  over  the  body.  Other  varieties 
of  the  rash  are  also  found,  as  ecthymatous  pustules, 
papules,  tubercular  spots,  mucous  patches  ;  and  ulcera- 
tions, the  result  of  these  eruptions,  may  also  be  pre- 
sent. 


MUCOUS  PATCHES 


181 


When  ecthyma  is  seen  in  any  quantity,  the  aggregation 
of  the  pustules  presents  a  very  peculiar  appearance,  and 
the  general  aspect  of  a  part  covered  with  such  an  eruption 
differs  entirely  from  that  just  described.  The  eruption  is 
usually  seated  on  the  buttocks  and  perinseum,  and  the 
pustules  are  more  or  less  closely  aggregated,  the  colour  of 
the  part  varying  according  to  the  degree  to  which  the 
pustules  are  separated.  When  crowded  together,  the 
general  tint  is  a  deep  purple — not  uniform,  but  broken 
up  into  patches  of  purple,  separated  by  intervals  where 
the  colour  is  red.  When  the  pustules  are  more  widely 
apart,  each  one  is  seen  to  consist  of  a  violet-coloured 
blotch,  crowned  with  a  thick,  blackish  crust,  and  sur- 
rounded by  a  deep  red  or  copper- coloured  areola.  If 
placed  sufficiently  closely,  the  adjacent  areolae  may  join, 
so  that  all  of  the  skin  which  is  seen  between  the  neigh- 
bouring pustules  is  of  the  same  reddish  or  coppery 
hue.  The  scabs  cover  an  ulcer,  which  is  apt  rapidly  to 
deepen,  and,  unless  checked  by  early  treatment,  may 
penetrate  deeply  into  the  tissues,  and  produce  very  serious 
results. 

The  ulcerations  which  arise  from  the  other  forms  of 
eruption  are  often  linear,  and  are  compared  by  Trousseau 
to  the  narrow  grooves  found  in  worm-eaten  wood.  They 
frequently  leave  linear  cicatrices,  which  may  exist  for  a 
long  time  an  evidence  of  the  past  disease. 

Mucous  patches,  when  they  occur  on  the  skin,  are  seen 
as  round  or  oval,  slightly  elevated  patches.  They  are 
soft,  and  something  of  the  consistence  of  mucous  mem- 
brane. Their  colour  is  reddish  or  greyish,  and  the  surface 
is  kept  constantly  moist  by  a  thin,  offensive  secretion. 
They  are  usually  found  by  the  side  of  the  anus,  at  the 
commissures  of  the  lips,  about  the  genitals,  between  the 
fingers  and  toes,  or  anywhere  else  where  the  skin  is  espe- 
cially delicate  and  moist.  When  they  occur  on  the  mucous 
membranes,  they  are  commonly  seen  as  irregularly- rounded 


182 


INHERITED  SYPHILIS 


white  elevations,  in  the  centre  of  which  a  point  of  excava- 
tion shows  itself ;  this  spreads,  so  that  after  a  very  short 
time  only  a  single  ulcer  is  observed.  It  is  not  uncommon 
to  find  them  on  the  arches  of  the  fauces,  but  they  seldom 
or  never  extend  to  the  back  of  the  pharynx. 

The  skin  of  a  syphilitic  child  is  dry  and  parchment-like, 
and  is  often  scaly,  especially  on  the  palms  of  the  hands 
and  the  soles  of  the  feet.  Fissures  are  often  seen  between 
the  fingers  and  toes,  and  may  be  found  radiating  from  the 
anus  and  the  corners  of  the  mouth,  and  at  the  commis- 
sures of  the  eyelids. 

A  kind  of  whitlow  is  occasionally  present  from  specific 
inflammation  and  suppuration  of  the  matrix  of  the  nail. 
The  nutrition  of  the  nail  being  thus  interfered  with  it 
gets  dry,  and  falls  off.  M.  Bouchut  states  that  he  has 
seen  a  case  in  which  every  nail,  both  on  the  fingers  and  on 
the  toes,  was  thus  affected. 

The  hairs  of  the  eyelashes  and  eyebrows  often  fall  out ; 
the  edges  of  the  eyelids  then  become  scaly.  The  colour 
of  the  face  is  yellowish,  and  has  been  compared  by  Sir 
W.  Jenner  to  the  colour  of  weak  cafe-au-lait.  It  is  diffe- 
rent from  the  earthy  tinge  often  seen  in  chronic  diarrhoea, 
and  must  not  be  confounded  with  it.  This  tint  does  not 
spread  to  the  rest  of  the  body,  but  remains  limited  to  the 
face,  where  it  is  most  marked  on  the  more  prominent 
parts,  being  less  noticeable  on  the  deeper  parts,  as  the 
internal  angle  of  the  orbit,  and  the  hollow  of  the  lower 
lip.  Besides  this  peculiar  tint  of  the  face,  there  is  a  very 
striking  pallor  of  the  body  generally,  which  is  very  slow 
to  disappear,  even  after  the  subsidence  of  the  other 
symptoms. 

The  cry  of  the  infant  is  one  of  the  most  noticeable 
features  of  the  disease ;  it  is  hoarse  and  high  pitched, 
and  when  once  heard  is  not  difiicult  to  recognise  again. 
Its  peculiar  quality  is,  no  doubt,  due  to  an  extension  of 
the   mucous   patches   to   the  larynx.    Occasionally  the 


DISEASE  OF  BONE 


183 


hoarseness  is  accompanied  by  attacks  of  laryngismus 
stridulus. 

As  a  rule  the  fontanelle  in  children  suffering  from  this 
disease  is  very  widely  open.  It  appears  as  if  the  cachexia 
exercised  some  influence  in  retarding  ossification  of  the 
bones.  Strangely  enough,  however,  the  growth  and 
development  of  the  teeth  do  not  appear  to  suffer  ;  indeed 
the  contrary  is  found  to  be  the  case,  for  the  teeth  are 
often  cut  very  early,  and  with  remarkable  ease.  It  is  not 
uncommon  to  see  the  front  teeth  appear  while  the  body 
is  jet  covered  with  the  syphilitic  rash. 

Disease  of  the  bones  has  been  lately  shown  to  be 
common  in  hereditary  syphilis,  and  should  be  always 
looked  for.  In  the  long  bones  it  may  be  easily  detected 
by  placing  the  finger  and  thumb  one  on  each  aspect  of 
the  bone,  and  passing  the  hand  downwards  along  the 
shaft.  If  diseased,  the  lower  end  of  the  bone  is  felt  to 
be  abnormally  thick,  and  this  thickening  is  best  marked 
at  the  point  of  junction  of  the  shaft  with  the  epiphysis. 
The  disease,  when  it  occurs,  occurs  as  an  early  symptom, 
and  is  said  always  to  be  present  in  dead  syphilitic  chil- 
dren, whether  stillborn  or  not.  It  is  never  confined  to  a 
single  bone,  and  usually  attacks  several.  The  bone 
which  least  often  escapes  is  the  femur,  and  then  follow 
in  order  of  frequency,  the  humerus,  tibia,  ulna,  radius, 
fibula,  the  bones  of  the  skull,  the  ribs,  ileum,  scapula, 
clavicle,  os  calcis,  astragalus,  metatarsal  and  metacarpal 
bones.  Sometimes,  notably  in  a  case  recorded  by  Kobner, 
the  bone  affection  is  the  only  evidence  of  the  hereditary 
disease.  The  various  lesions  of  bone  are  described  in 
treating  of  the  morbid  anatomy  of  the  disease. 

In  severe  cases  suppuration  takes  place  outside  the 
joint,  and  the  epijDhysis  separates  from  the  shaft.  The 
child  then  presents  very  characteristic  symptoms.  There 
is  complete  immobility  of  the  limbs,  as  if  the  bones  had 
been  fractured.    The  arms  lie  pronated  by  the  side  of 


184 


INHERITED  SYPHILIS 


the  body ;  the  legs  are  stretched  out  straight  in  the  cot, 
and  when  the  child  is  lifted  np,  hang  loose,  swaying  from 
side  to  side.  On  examination,  crepitation  can  be  some- 
times produced  between  the  shaft  of  the  bone  and  the 
epiphysis.  The  joints  are  very  tender  to  pressure,  and 
if  an  abscess  forms,  become  bent  and  stiff  and  exquisitely 
painful. 

Besides  this  disease  of  the  articular  ends  of  the  bones, 
nodes  may  be  present  in  the  shafts  of  the  long  bones, 
giving  rise  to  much  tenderness  and  aching  pain.  In- 
durated deposits  are  also  often  found  in  the  areolar  tissue, 
tendons,  and  muscles. 

Enlargement  of  the  posterior  cervical  glands  is  also  a 
common  lesion.  In  most  cases  of  infantile  syphilis 
enlarged  and  movable  glands  may  be  felt  in  the  nape  of 
the  neck,  immediately  below  the  occiput.  Sometimes 
the  lymphatic  enlargement  is  more  general,  and  the  liver 
and  spleen  can  also  be  felt  to  be  increased  in  size.  I 
used  to  be  of  opinion,  with  Dr.  Gee,  that  the  amount  of 
splenic  swelling  could  be  taken  as  a  measure  of  the  severity 
of  the  cachexia.  In  other  words,  that  it  was  only  in  the 
more  severe  cases  that  enlargement  of  the  spleen  took 
place  at  all,  and  that  if  the  swelling  was  considerable  the 
danger  was  great.  I  have  met  with  cases,  however,  which 
show  that  the  spleen  may  be  large  and  hard  although  the 
general  symptoms  are  mild  and  the  nutrition  of  the 
patient  satisfactory.  Some  time  ago  Dr.  A.  Leete  G-riffith 
sent  me  a  well-nourished  baby,  aged  four  weeks,  who  had 
begun  a  fortnight  previously  to  swell  about  the  abdomen. 
The  child's  complexion  was  dingy.  She  snuffled  a  little 
and  was  slightly  hoarse.  A  few  scaly,  coppery  spots  could 
be  seen  on  the  chin  and  in  the  left  arm-pit.  The  veins  of 
the  epigastrium  were  full.  The  liver  could  be  felt  three 
fingers'  breadths  below  the  ribs :  its  consistence  was  soft. 
The  spleen  reached  downwards  for  the  same  distance,  and 
its  substance  was  hard  and  resisting.  There  was  no  disease 


GENERAL  NUTRITION 


185 


of  bone.  The  mother  had  had  sore  throat  and  rash  at  an 
early  period  of  her  pregnancy.  The  baby  was  being  treated 
with  anti- syphilitic  remedies.  Four  months  afterwards 
Dr.  Griffith  wrote  to  me  that  the  spleen  had  become  greatly 
reduced  in  size,  and  that  the  child  was  going  on  well.  She 
was  being  brought  up  at  the  breast. 

In  this  case  the  increase  in  size  of  the  liver  was  pro- 
bably not  a  consequence  of  the  constitutional  disease,  for 
the  substance  of  the  organ  was  normal  in  consistence, 
and  presented  no  sign  of  induration.  The  spleen,  how- 
ever, was  large  and  hard,  but  still  the  cachexia  could  not 
be  called  severe,  for  the  symptoms  generally  were  excep- 
tionally mild.  Nutrition  was  good,  eruption  was  scanty, 
and  the  condition  of  the  child  was  never  such  as  to  excite 
anxiety. 

The  general  condition  of  the  infant  varies,  not  according 
to  the  severity  of  any  particular  symptom,  but  according 
to  the  intensity  of  the  general  cachexia.  The  child  some- 
times continues  plump,  and  although  pale  and  rather  weak, 
seems  to  suffer  comparatively  little  from  the  effects  of  the 
disease.  But  a  satisfactory  state  of  nutrition  is  the  excep- 
tion and  not  the  rule.  In  the  large  majority  of  cases  the 
cachexia  is  severe ;  and  even  when  the  more  special  sym- 
ptoms have  passed  away,  the  infant  is  apt  to  remain  pale, 
wasted  and  old-looking,  with  perhaps  a  permanent  stunting 
of  the  growth.  Dr.  Donkin  has  laid  stress  upon  the  inten- 
sity and  persistence  of  this  interference  with  the  nutritive 
processes,  and  suggests  that  an  explanation  may  possibly 
be  found  in  a  fibrosis  of  the  pancreas  such  as  is  common 
in  other  of  the  internal  organs. 

In  inherited  syphilis,  as  in  the  acquired  form,  many 
varieties  of  nervous  disease  are  to  be  met  with.  Sudden 
hemiplegia  has  been  ascribed  by  Dr.  Hadden  to  arterial 
degeneration  inducing  thrombosis  or  haemorrhage.  This 
observer,  out  of  twenty-five  cases  of  hemiplegia  with  acute 
onset,  found  two  in  which  the  children  were  certainly 


186 


INHERITED  SYPHILIS 


syphilitic  and  eleven  others  in  which  suspicion  of  this 
disease  was  more  or  less  strong.  Dr.  Abercrombie,  out  of 
fifty  cases,  attributed  four  to  syphilis,  and  had  strong  sus- 
j)icions  about  two  others.  In  addition  to  these  acute  cases, 
more  chronic  disease  has  also  been  ascribed  to  a  specific 
taint.  There  is  little  doubt  that  cerebral  sclerosis  and  dis- 
seminated sclerosis  of  the  cord  occurring  in  young  subjects 
may  have  this  origin  ;  and  persistent  cervical  opisthotonos 
from  basic  meningitis  is  sometimes  associated  with  sym- 
ptoms of  the  inherited  complaint. 

A  peculiar  form  of  paralysis  has  been  described  which 
affects  the  anterior  branches  of  the  brachial  plexus,  and 
induces  a  more  or  less  complete  loss  of  power  in  the  upper 
limbs.  Sensibility,  however,  remains  normal.  Henoch 
has  noted  two  cases  in  which  all  the  muscles  of  the  upper 
extremities  were  paralysed  with  the  exception  of  the  flexors 
of  the  fingers.  Other  signs  of  syphilis  were  present  and 
under  specific  treatment  the  paralysis  soon  disappeared. 

In  rare  cases  the  symptoms  of  hereditary  syphilis  are 
delayed  until  the  seventh,  ninth,  tenth,  or  even  fourteenth 
year.  Coppery,  scaly  eruptions  may  then  appear,  with 
discharges  from  the  ears,  nose,  &c.  Chronic  interstitial 
keratitis  may  also  occur  at  these  times,  and  is  symptomatic 
of  hereditary  syphilis.  There  may  also  be  deafness  from 
some  morbid  condition  of  the  auditory  nerves.  The  per- 
manent central' incisors  (Hutchinson's  teeth)  are  often  im- 
perfectly developed.  They  are  short  and  narrow  and  do 
not  touch,  so  that  a  space  is  left  in  the  gum  on  each  side. 
At  the  same  time  the  edges  are  uneven  from  atrophy  of  the 
middle  lobe,  so  that  a  broad,  vertical  notch  is  left  in  the 
centre  of  the  edge,  from  which  a  shallow  furrow  or  groove 
may  pass  backwards  on  both  anterior  and  posterior  sur- 
faces nearly  to  the  gum.  The  notching  is  usually  sym- 
metrical, but  not  always,  for  sometimes  only  one  tooth  is 
affected.  These  symptoms  may  be  found,  not  only  when 
the  disease  is  thus  deferred,  but  also  when  it  has  appeared 


RELAPSES 


187 


at  the  ordinary  time  during  infancy.  They  are  not,  how- 
ever, by  any  means  constant. 

E-elapses  are  very  liable  to  occur  in  children  after  the 
cessation  of  all  symptoms,  and  when  the  disease  is  sup- 
posed to  be  cured.  Probably  many  of  the  cases  of  so- 
called  delayed  syphilis  are  merely  instances  of  relapse,  the 
earlier  symptoms  of  the  disease  having  been  unnoticed  or 
misapprehended.  When  the  relapse  takes  place  at  an 
earlier  period  it  is  most  commonly  observed  in  the  form 
of  mucous  patches  with  large  thickened  elevated  edges 
seated  by  the  side  of  the  anus,  at  the  angle  of  the  mouth, 
on  the  tongue,  or  between  the  fingers  and  toes.  These 
may  be  combined  with  a  return  of  the  eruption  on  the 
skin.  In  cases  where  the  disease  reappears  after  an  in- 
terval of  years  it  usually  manifests  itself  by  more  deep- 
seated  lesions,  such  as  are  considered  characteristic  of 
the  later  or  third  stage  :  chronic  interstitial  keratitis  occurs  ; 
the  permanent  incisors  appear  notched  and  dwarfed  ;  there 
is  deafness  and  more  or  less  serious  disease  of  bone.  The 
following  case,  seen  by  the  writer,  under  the  care  of  the 
late  Dr.  Semple,  affords  a  good  illustration  of  relapsed 
syphilis  : 

A  girl,  aged  eighteen,  suffered  from  chronic  interstitial 
keratitis  of  one  eye,  applied  for  advice  on  account  of  "  sore 
throat."  On  examination  of  the  fauces  extensive  ulcerative 
disease  was  discovered,  which  had  destroyed  the  whole  of 
the  soft  palate,  and  the  greater  part  of  the  bony  roof  of 
the  mouth.  The  teeth  were  not  notched,  nor  were  there  any 
nodes  on  the  shin  bones.  On  enquiry  it  appeared  that  the 
mother  had  been  a  healthy  woman  before  her  marriage,  but 
that  after  the  birth  of  her  first  child  she  had  begun  to 
suffer  from  sore-throat,  and  to  have  an  eruption  on  the 
skin.  The  child  snuffled,  was  covered  with  a  rash,  and  died 
after  a  few  weeks.  The  six  following  children  died  in  the 
same  way.  They  were  all  born  at  the  full  time,  and  ap- 
peared to  be  healthy,  but  a  few  weeks  after  birth  each  began 


188 


INHERITED  SYPHILIS 


to  snuffle  ;  the  characteristic  rash  appeared  ;  and  the  infant 
wasted  and  died.  The  patient  herself,  although  the  eighth 
child,  was  the  first  who  had  survived.  She  had  the  ordinary 
symptoms  of  inherited  syphilis  soon  after  birth.  At  ten 
years  old  the  eye  became  affected  with  keratitis.  At  the 
age  of  twelve  she  first  began  to  complain  of  the  affection 
of  the  throat,  from  which  she  had  since  been  suf- 
fering. 

This  case  is  fortunately  an  exceptional  one.  As  a  rule 
the  symptoms  cease  after  a  time  and  never  return  ;  nutri- 
tion goes  on  well,  and  the  patient  to  all  appearance  is  as 
strong  as  other  children  of  his  age.  It  may  happen,  how- 
ever, that  recovery  is  less  complete,  and  although  there 
may  be  no  actual  relapses,  signs  may  be  noticed  hinting  at 
the  past  cachexia.  Thus,  nutrition  is  not  quite  satisfac- 
tory ;  the  body  is  stunted  ;  the  complexion  earthy ;  the 
hair  thin  and  brittle.  Traces  of  thickened  bone  may  be 
found,  and  sometimes  the  brain  suffers  so  that  the  child 
becomes  imbecile  or  epileptic. 

Morbid  Anatomy. — Inherited  syphilis  in  the  child  pro- 
duces very  widely  distributed  lesions ;  indeed,  there  is  no 
part  of  the  body  which  may  not  become  affected  as  a 
consequence  of  this  disease.  The  principal  lesions  are 
seated  in  the  bones,  the  mucous  membranes,  and  the  solid 
internal  organs. 

Syphilitic  affections  of  the  bones  have  been  made 
the  subject  of  careful  study ;  and  it  is  to  Drs.  Parrot  and 
Cornil  of  Paris  and  Taylor  of  New  York  that  we  are 
chiefly  indebted  for  complete  descriptions  of  these  im- 
portant lesions. 

The  long  bones  become  affected  by  a  special  suppurative 
osteochondritis  which  attacks  the  epiphysial  end  of  the 
bone. 

First,  the  layer  of  cartilage  which  is  preparing  for 
ossification  increases  in  width  so  as  to  be  twice  or  even 
four  times  its  natural  thickness  and  becomes  particularly 


MORBID  CHANGES  IN  BONE 


189 


transparent  and  soft.  This  increased  thickness  is  due  to 
a  multiplication  of  the  cartilage  cells,  which  lose  their 
natural  characters  and  assume  much  the  shape  and  size 
of  the  round  granulation  cells  of  syphilitic  gummata. 
At  the  same  time  the  intercellular  substance  is  diminished. 
The  layer  of  cartilage  which  is  actually  undergoing  ossifi- 
cation, instead  of  being  very  thin,  as  it  is  in  healthy  bone^ 
is  thickened  unevenly,  so  that  it  shows  on  section  as  a 
broad  uneven  line.  By  the  microscope,  its  ostioblasts  are 
found  to  be  replaced  more  or  less  completely  by  small 
granulation  cells  or  spindle-shaped  elements.  The  already 
ossified  bone  immediately  in  contact  with  the  last  layer  is 
altered  in  colour  on  the  surface,  being  marked  with 
patches  of  white  or  yellow  or  gray  splashed  with  rose. 

After  a  time  destructive  changes  set  in  in  the  bony 
tissue.  Parrot  describes  a  "  gelatiniform  softening "  in 
which  the  bone  is  replaced  by  a  soft,  rather  transparent 
material  of  a  yellowish  or  brown  colour.  When  this 
dries,  after  death  or  exposure  of  the  bone  to  the  air,  a 
cavity  is  left.  A  puriform  matter,  too,  sometimes  in- 
filtrates the  cancellous  structure,  so  that  the  canuUse 
disappear,  and  leave  cavities  filled  with  the  pus-like  sub- 
stance. The  result  of  this  lesion  is  to  produce  separation 
of  the  epiphysis  with  the  ossifying  layer  from  the  shaft  of 
the  bone.  This  is  followed  by  suppuration  round  the 
affected  part,  but  the  joint  itself  is  not  involved.  Under 
the  microscope,  the  puriform  matter  is  seen  to  consist,  not 
of  true  pus,  but  of  small  angular  but  still  roundish  elements 
which  replace  the  natural  lymphoid  and  myeloid  cells. 

Another  form  of  bone  lesion,  which  Parrot  has  called 
**  periosteogenesis,"  begins  as  a  periostitis,  and  attacks 
principally  the  humerus  and  tibia.  Parrot  has  described 
two  forms : — the  osteoid,  which  may  begin  at  the  earliest 
period  of  life,  and  the  spongioid  or  rachitic,  which  is 
seldom  met  with  before  the  age  of  six  Qionths. 

In  the  first — the  osteoid  form — a  new  osteoid  growth 


190 


INHERITED  SYPHILIS 


forms  on  the  surface  of  the  shaft  beneath  the  periosteum, 
which  is  thickened  and  adherent  to  it.  The  new  growth 
is  white  and  chalky  in  appearance  from  infiltration  of 
calcareous  salts :  and  by  its  colour  is  readily  distinguish- 
able from  the  bone  beneath.  It  is  composed  of  inter- 
lacing trabeculse,  lying  perpendicularly  to  the  axis  of  the 
shaft,  and  in  place  of  the  bone  corpuscles,  which  in 
normal  osseous  tissue  are  disposed  regularly  around  the 
Haversian  canals,  contains  many-sided  stellate  corpuscles 
which  anastomose  by  their  processes  with  the  cells  of  the 
periosteum  and  with  one  another. 

The  spongioid  form  consists  of  fibrous  tissue,  grey  or 
yellowish  in  colour,  and  very  vascular. 

These  two  forms  of  new  growth  may  be  combined  in 
the  same  subject,  lying  in  alternate  layers.  The  bone 
beneath  is  either  unaltered  in  structure,  or  is  more  porous 
and  brittle  than  in  the  normal  state  from  absorption  of 
calcareous  matter  and  the  formation  of  furrows  filled  with 
medulla. 

The  bones  of  the  skull  may  be  attacked  by  both  forms 
of  the  disease.  Grelatiniform  softening  is,  however,  com- 
paratively rare  in  this  situation,  and  when  present  (which 
is  only  in  the  youngest  infants)  rarely  penetrates  deeply 
into  the  bone.  The  osteoid  growths  are  more  common, 
and  attack  the  older  children.  These  lesions  occupy  the 
frontal,  parietal,  and  occipital  bones ;  but  are  especially 
frequent  in  the  parietal  in  the  neighbourhood  of  the  an- 
terior fontanelle.  The  deformity  which  results  is  a  very 
characteristic  one.  Four  elevations,  intersected  by  two 
furrows  placed  crosswise,  are  found,  and  a  condition  is 
produced  which  has  been  aptly  compared  to  a  hot  cross 
bun."  These  osteophytes  are  thickened  and  porous,  and 
the  bones  themselves  may  be  lighter  and  more  porous  than 
natural. 

Another  lesion  is  sometimes  seen  which  is  similar  to  the 
cranio  tabes  so  common  in  rickety  children.    The  bone  is 


SYPHILITIC  CTYLITIS 


191 


thinned  in  spots  of  varying  size  and  may  even  be  perfo- 
rated. This  lesion  is  most  common  in  the  occipital  bone, 
and  is  due  to  pressure  as  the  child's  head  rests  on  the 
pillow. 

Dr.  Taylor,  of  New  York,  has  described  a  syphilitic 
dactylitis  which  attacks  the  bones  of  the  hands  and  feet. 
This  affection  begins  in  the  fibrous  tissue  and  produces 
a  slight  enlargement  of  one  or  more  phalanges  or  an 
entire  digit.  It  excites  little  pain,  but  interferes  to  some 
extent  with  free  movement  of  the  joint.  Another  form 
sometimes  occurs  in  which  the  disease  originates  in  the 
bone  and  periosteum.  This  variety  most  often  attacks  the 
fingers.  One  or  more  of  the  phalanges  becomes  thickened 
and  fusiform.  If  the  swelling  is  injured  the  skin  becomes 
swollen,  red,  and  tense,  and  ulcerating  discharges  a  soft 
detritus  mixed  with  pus.  Limited  necrosis  may  follow 
and  lead  to  shortening  of  the  finger.  If  not  injured,  the 
swelling  tends  to  resolve  without  breach  of  surface. 

The  above  described  changes  in  the  long  bones  may 
occur  within  a  few  weeks  of  birth,  or  even  during  intra- 
uterine life.  The  lesions  of  the  cranial  bones  occur  later 
than  the  others,  and  are  comparatively  rare  under  two 
years  of  age. 

The  mucous  membranes  of  syphilitic  children  are  very 
liable  to  catarrh,  and  may  be  the  seat  of  mucous  patches, 
erosions,  and  ulcers.  These  lesions  are  often  found  on  the 
inside  of  tlie  cheek,  lips,  and  fauces ;  but  are  rare  at  the 
back  of  the  pharynx,  and,  according  to  Dr.  John  Mac- 
kenzie, never  spread  into  the  gullet.  Sometimes,  however, 
they  are  found  in  the  intestine.  Mucous  patches  and 
ulcers  also  occur  on  the  mucous  membrane  lining  the  air 
passages.  In  fatal  cases  they  may  be  seen  on  the  epiglottis 
and  sides  of  the  glottis,  and  sometimes  extend  into  the 
larger  air  tubes.  In  some  cases  the  vocal  cords  are  de- 
stroyed by  ulceration ;  in  others,  they  are  the  seat  of 
warty  growths. 


192 


INHERITED  SYPHILIS 


In  the  interyial  organs  new  fibroid  growths  appear,  which 
may  be  diffused  or  circumscribed.  In  the  lungs  many 
different  pathological  conditions  have  been  enumerated 
as  dependent  upon  a  syphilitic  taint — so  many,  that  in 
all  probability  sufficient  care  has  not  always  been  taken 
to  discriminate  between  pulmonary  disease  occurring  in 
a  syphilitic  infant  and  real  syphilitic  disease  of  the  lung. 
A  syphilitic  infant  may  become  infected  with  tubercle,  as 
Hochsinger  has  proved  by  cases  lately  published,  and  may 
die,  not  from  the  inherited  taint,  but  from  extensive  tuber- 
culous disease  of  the  lungs.  Therefore  in  cases  of  pul- 
monary consolidation  occurring  in  a  syphilitic  infant 
search  should  always  be  made  for  the  tubercle  bacillus. 
A  syphilitic  pneumonia  has  been  described  in  which  the 
lung  becomes  the  seat  of  a  grey  consolidation,  which  on 
section  presents  a  smooth  shining  surface  traversed  by 
fine  fibrous  lines.  It  is  very  dense  and  tough.  Under 
the  microscope  the  alveolar  walls  are  seen  to  be  infiltrated 
with  round  cells,  spindle  cells,  and  fibrous  tissue.  This 
change  is  no  doubt  met  with  occasionally  in  syphilitic 
children,  but  that  it  is  peculiar  to  subjects  of  this  disease 
has  yet  to  be  proved. 

The  new  formation  called  "gumma"  has  long  been 
recognised  as  a  consequence  of  syphilis.  In  the  lung 
gummata  are  seen  as  rounded  masses,  usually  of  the  size 
of  a  nut,  and  yellowish- white  in  colour.  Their  consist- 
ence is  firm  at  the  circumference,  but  in  the  centre  they 
are  softer,  and  the  interior  is  sometimes  broken  down 
into  a  small  cavity  containing  ^^uriform  matter.  Micro- 
scopic examination  shows  the  alveolar  walls  at  the  circum- 
ference of  the  tumour  to  •  be  infiltrated  with  nucleated 
cells  which  cause  more  or  less  compression  of  the  alveoli. 
Nearer  the  centre  round  or  oval  cells  are  seen  in  a  finely 
reticulated  tissue.  The  central  portion,  if  softened,  con- 
sists of  fatty  molecular  granules. 

The  liver  is  hypertrophied  and  indurated,  either  gene- 


MORBID  CHANGES  IN  THE  LIVER  193 

rally  or  partially,  the  enlargement  being  sometimes  con- 
fined to  one  lobe,  or  to  a  part  of  one  lobe.  Specific  disease 
of  the  liver,  when  it  occurs,  is  an  early  sign  of  the  cachexia. 
It  rarely  gives  rise  to  jaundice  or  ascites.  If  the  latter 
symptom  be  present,  it  is  probably  due  to  concurrent 
peritonitis.  The  hepatic  lesion  has  always  been  considered 
to  add  greatly  to  the  danger  of  the  patient ;  but  Hoch- 
singer  states  that  of  forty- six  syphilitic  infants  under  his 
care  in  whom  decided  enlargement  of  the  liver  was  noted, 
only  sixteen  died.  In  the  others  very  speedy  reduction  of 
the  size  of  the  organ  took  place  under  specific  treatment. 
The  enlarged  liver  feels  smooth  and  hard  to  the  touch,  and 
is  usually  accompanied  by  very  obvious  signs  of  digestive 
derangement.  Sometimes  the  pressure  of  the  enlarged 
liver  upon  the  vena  cava  may  produce  extensive  oedema  of 
the  lower  limbs  and  of  the  scrotum.  This  was  seen  by 
the  writer  in  a  case  in  which  the  syphilitic  symptoms 
appeared  a  fortnight  after  birth.  There  was  obstinate 
constipation  and  vomiting,  and  the  mucous  membrane  of 
the  mouth  was  covered  with  thrush.  1'he  heart  and  lungs 
were  healthy.  The  infant  rapidly  sank  and  died.  Gubler, 
who  drew  attention  to  this  condition  of  the  liver  as  a  result 
of  syphilis,  describes  the  organ  in  highly  marked  cases  as 
hypertrophied,  globular,  hard,  and  elastic.  It  is  extremely 
resistant  to  pressure,  and  creaks  under  the  knife  when  cut 
into.  On  section  the  natural  appearance  of  the  surface  is 
seen  to  be  quite  lost,  and  in  its  stead  we  see  layers  of 
small,  white,  opaque  grains  on  a  yellowish  uniform  ground. 
'No  blood,  but  only  a  little  yellowish  serum,  escapes  on 
pressure.  The  capillary  vessels  are  obliterated,  and  the 
calibre  of  the  larger  vessels  is  considerably  diminished. 
These  changes  are  due  to  the  development  of  large  quanti- 
ties of  fibro-plastic  tissue,  which  compresses  the  hepatic 
cells,  obliterates  the  vessels,  and  consequently  prevents  the 
secretion  of  bile  in  the  parts  so  affected.  Sometimes  the 
disease  is  confined  to  circumscribed  deposits  (gummata) 

13 


194 


INHERITED  SYPHILIS 


embedded  in  the  substance  of  the  organ,  which  is  other- 
wise healthy ;  but  hepatic  gummata  are  very  rare  in 
infants. 

The  spleen  is  often  enlarged,  but  seldom  to  any  con- 
siderable extent.  Dr.  J.  A.  Coutts  found  definite  increase 
in  size  of  the  organ  in  62  per  cent,  of  his  cases.  As  in  the 
liver,  the  hypertrophy  is  due  to  a  diffused  interstitial 
hyperplasia. 

Changes  have  also  been  observed  in  the  heart  and 
kidneys.  These  organs,  even  when  healthy  to  the  naked 
eye,  are  sometimes  found,  on  closer  examination,  to  be 
undergoing  interstitial  changes.  In  some  specimens  pro- 
duced by  Dr.  Coupland  before  the  Pathological  Society 
the  heart  showed,  under  the  microscope,  an  almost  uni- 
versal infiltration  of  small  round  cells  amongst  the 
muscular  fibres  ;  and  the  kidneys,  although  presenting  to 
the  naked  eye  a  normal  appearance,  were  found  to  be 
undergoing  similar  changes. 

Huber  has  found  the  supra-renal  capsules  affected  in 
some  cases.  In  one  well-marked  example  the  capsules 
were  large,  greyish  on  the  outside,  translucent  and  thick, 
with  numerous  white,  irregularly- shaped  spots  inter- 
sjDersed  in  the  capsular  substance.  At  the  posterior 
surface  of  both  capsules  were  irregular  yellow  thick  knots, 
showing,  under  the  microscope,  fatty  detritus. 

These  affections  of  the  internal  organs  do  not  seem  to 
stand  in  any  direct  relation  to  the  general  symptoms.  In 
cases  where  the  latteV  are  very  severe,  and  the  influence 
of  the  disease  upon  nutrition  is  most  powerfully  mani- 
fested, the  liver  and  spleen  may  present  no  sign  of  patho- 
logical change.  In  other  cases,  again,  these  organs  may 
suffer  severely,  while  the  external  characters  of  the  disease 
are  but  faintlj  marked. 

Diagnosis. — In  a  well-marked  case  of  inherited  syphilis, 
the  wizened  face,  the  snuffling,  the  peculiar  complexion, 
the  hoarse  cry,  the  emaciation,  the  dry  and  parchment- 


DIAGNOSIS 


195 


like  skin  with  the  characteristic  eruption  scattered  over 
the  surface,  the  fissured  lips  and  anus,  form  a  collection 
of  symptoms  which  when  once  seen  it  is  impossible  after- 
wards to  mistake.  We,  however,  constantly  find  cases  in 
which  many  of  the  symptoms  are  absent.  The  child  may 
continue  plump,  and  be  apparently  in  good  condition; 
but  here  there  is  usually  snuffling;  rust- coloured  spots 
are  found  about  the  perinseum,  and  fissures  will  be  seen 
radiating  from  the  anus  and  perhaps  from  the  corners  of 
the  mouth.  The  general  pallor  of  the  skin  is  seldom 
absent,  although  the  special  "  cafe-au-lait "  tint  of  the 
complexion  may  not  be  noticed.  The  deep  purple  tint 
produced  by  a  collection  of  ecthymatous  pustules  presents 
a  very  characteristic  appearance,  and  one  which  it  is 
difficult  to  mistake,  especially  when  it  is  combined  with 
the  cracks  and  ulcerations  about  the  anus,  &c.  The 
appearance  alone  of  ecthyma  in  an  infant  should  lead  us 
to  suspect  syphilis.  Scabies  is  the  only  other  cause  which 
is  found  to  produce  such  pustules  at  this  early  age,  and 
this  is  at  once  detected  by  the  absence  of  the  other  signs 
of  syphilis,  by  the  fewer  number  of  the  pustules,  and  by 
the  presence  of  the  characteristic  furrow  peculiar  to  the 
acarus. 

We  must  be  careful  not  to  overrate  the  value  of  snuffling 
as  a  sign  of  the  inherited  taint.  Standing  alone,  it  may  mean 
very  little.  Snuffling  is  common  in  young  babies,  and  if 
accompanied  by  a  profuse  discharge  from  the  nasal  pas- 
sages is  a  familiar  consequence  of  post-nasal  catarrh 
dependent  upon  adenoid  vegetations.  Hoarseness,  again, 
is  a  recognised  indication  of  the  same  catarrhal  state ;  so 
that  snuffling  and  hoarseness  combined  are  not  to  be 
relied  upon  as  evidence  of  syphilis.  In  the  same  way 
enlargement  of  the  spleen  may  be  due  to  a  variety  of 
causes,  and  may  be  joined  with  the  two  preceding  symptoms 
in  a  child  who  is  perfectly  sound.  In  all  cases  of  suspected 
syphilis  we  should  notice  the  state  of  general  nutrition, 


196 


INHERITED  SYPHILIS 


and  make  careful  search  for  spots.  A  syphilitic  baby  is 
generally  thin  and  flabby ;  his  f  ontanelle,  as  a  rule,  is 
widely  open;  his  eyebrows  and  eyelashes  are  scanty  or 
absent ;  his  teeth  begin  very  early  to  appear.  Dr.  J.  A. 
Coutts  is  of  opinion  that  obstinate  wasting  unaccompanied 
by  vomiting  or  diarrhoea,  forms  a  sufficient  justification  for 
anti- syphilitic  treatment ;  but  I  should  hesitate  to  treat  a 
child  for  the  specific  disease  upon  this  evidence  alone. 

If  in  doubt  in  any  case,  after  a  careful  examination  of 
the  child's  whole  body,  we  should  inquire  into  the  health 
of  the  other  children,  examine  them  for  signs  of  past 
disease,  and  question  the  parents  as  to  their  own  health, 
especially  as  to  the  occurrence  of  previous  miscarriages 
on  the  part  of  the  mother. 

When  the  cachexia  has  been  pronounced,  its  consequences 
remain  visible  long  after  the  disease  has  passed  away.  The 
physical  development  of  the  child  may  be  unsatisfactory, 
and  often  his  complexion  is  ashy  or  earthy  in  tint.  Ves- 
tiges of  local  disease  may  be  noticed,  such  as  flattened 
bridge  of  the  nose  from  long- continued  swelling  of  the 
nasal  mucous  membrane  when  the  bones  are  soft ;  markings 
of  the  skin  by  little  pits,  or  linear  cicatrices,  from  former 
ulceration,  especially  about  the  angles  of  the  mouth ;  pro- 
tuberant forehead  from  specific  disease  of  the  frontal  bone 
and  the  characteristic  thickening  of  the  cranial  bones 
around  the  anterior  f ontanelle.  Cranio-tabes  alone  is  no 
indication  of  syphilis,  as  it  may  occur  quite  independently 
of  any  specific  taint.  There  may  be  interstitial  keratitis 
of  the  eye,  notching  and  dwarfing  of  the  permanent  teeth, 
and  even  deafness  from  disease  of  the  auditory  nerve. 
Often,  too,  the  spleen  is  left  swollen  and  hard.  Moreover, 
it  must  not  be  forgotten  that  nervous  derangements  due 
to  cerebral  sclerosis  or  to  arterial  and  other  degenerations 
may  be  set  up  as  a  consequence  of  the  inherited  taint. 

Causation. — The  disease  may  be  conveyed  from  parents 
to  children  through  the  influence  of  the  father,  the  mother. 


CAUSATION 


197 


or  both  together.  Either  alone  may  be  suffering,  for  it 
can  now  be  taken  as  proved  that  disease  in  one  parent, 
where  the  infant  is  tainted,  does  not  necessarily  imply 
disease  in  the  other.  When  the  father  is  the  source  of 
infection  the  mother  may  bear  a  syphilitic  child,  but  herself 
remain  healthy  ;  or,  again,  the  offspring  of  a  healthy  father 
may  be  infected  by  a  diseased  mother,  the  father  remaining 
free. 

The  father's  power  of  transmitting  the  disease  continues 
for  years,  and  may  long  outlast  all  outward  signs  of  the 
complaint  in  his  own  person.  It  appears  certain  also  that 
the  taint  so  transmitted  is  as  active  and  intense  after  a 
term  of  years  as  it  is  in  the  beginning.  It  is  true  that 
when  a  syphilitic  man  and  a  healthy  woman  are  the 
parents  of  many  children  the  severity  of  the  complaint 
is  seen  gradually  to  decline  in  each  succeeding  infant,  but 
this  is  not  necessarily  a  proof  that  the  virus  in  the  man  is 
losing  its  power.  All  evidence  tends  to  show  that  a  man, 
as  long  as  he  is  capable  of  transmitting  it  at  all,  will 
transmit  the  disease  in  as  active  a  form  in  the  latest  as  in 
the  earliest  period  after  contracting  it.  It  seems  rather, 
as  Dr.  Coutts  suggests,  that  this  seeming  attenuation  is 
due  to  the  reabsorption  by  the  mother  of  some  product 
generated  in  the  foetus — an  antitoxin  which  is  potent  in 
proportion  to  the  number  of  her  previous  pregnancies. 
By  this  means  the  mother  may  be  made  immune  while 
retaining  her  health ;  and  Colles'  law  that  the  complaint  is 
not  conveyed  from  the  child's  mouth  to  the  mother's  breast 
may  hold  good  without  being  in  any  way  proof  that  the 
mother  herself  is  a  sufferer  from  the  disease.  But  the 
actual  infectiousness  of  inherited  syphilis  has  been  greatly 
exaggerated.  Authentic  instances  in  which  the  disease 
has  been  contracted  by  a  healthy  person  from  an  infant  so 
afflicted  are  few  indeed.  It  has  happened  occasionally 
that  a  suckling  at  the  breast  has  infected  his  nurse,  and 
one  case  has  come  under  my  own  notice  in  which  a  child 


198 


INHERITED  SYPHILIS 


infected  the  nipple  of  its  mother ;  but  such  cases  are  ex- 
cessively rare,  and  the  disease,  as  it  occurs  in  the  infant  as 
a  result  of  inheritance,  may  be  said  to  be  practically  non- 
infectious. 

Mercurial  treatment  in  the  father  has  the  effect,  not 
perhaps  of  enfeebling  the  virus,  but  of  destroying  for  a 
time  the  power  of  transmitting  it ;  but  this  power  may 
return  later  when  the  influence  of  treatment  has  worn 
away.  In  connection  with  this  point  is  the  question.  How 
soon  should  a  man  be  allowed  to  marry  after  contracting 
the  disease  ?  To  this  Mr.  Hutchinson  answers  that prob- 
ably in  the  vast  majority  of  cases  the  risk  of  transmission 
to  children  is  over  long  before  the  end  of  two  years,"  but 
other  authorities  would  extend  this  term  to  three,  four,  or 
five  years.  Dr.  Coutts  fixes  the  term  at  two  years  after 
the  disappearance  of  all  active  symptoms  if  treatment 
has  been  thorough,"  and  this  I  think  a  reasonable  con- 
clusion. 

In  cases  where  the  mother  alone  is  syjDhilitic  the  infant 
is  more  severely  affected  than  in  cases  where  the  father 
alone  is  diseased.  Most  authorities,  however,  agree  in 
stating  that  the  complaint  in  the  mother  must  have  dated 
from  before  conception,  and  that  a  syphilis  contracted 
during  pregnancy  is  not  commonly  transmitted  to  the 
offspring.  Still  we  cannot  feel  sure  in  any  individual 
case  that  the  child  will  certainly  escape. 

If  both  parents  are  diseased  the  infant  is  very  unlikely 
to  be  spared,  and  is  indeed,  as  a  rule,  infected  more 
heavily  than  in  cases  where  the  complaint  is  inherited 
from  one  side  only.  Abortions  are  common,  and  in  the 
children  born  alive  a  high  death-rate  is  found.  Kassowitz 
estimates  this  at  50  per  cent. ;  Coutts  rates  it  more  highly 
still.  Statistics,  however,  on  this  subject  are  necessarily 
attended  with  some  uncertainty,  for  disturbing  influences, 
such  as  duration  of  disease  and  effects  of  treatment,  have 
to  be  reckoned  with  ;  but  all  observers  agree  that  the 


TWINS  UNEQUALLY  AFFECTED 


199 


measure  of  infection  is  least  wlien  the  father  only  is  re- 
sponsible for  the  transmission,  greater  when  the  mother 
alone  is  infected,  and  most  serious  when  both  parents 
join  hi  conveying  the  taint.  Still,  as  Dr.  Coutts  points 
out,  the  severity  of  infection  is  exercised  more  upon  the 
foetus  in  utero  than  upon  the  infant  after  birth,  and  is  not 
to  be  taken  as  an  element  in  estimating  the  probable 
chances  of  recovery  in  a  child  who  is  brought  for  treat- 
ment at  the  usual  age. 

In  the  case  of  twins  born  of  parents  the  subject  of  this 
disease,  the  two  children  are  not  necessarily  affected  to 
an  equal  degree.  Thus  "  Minnie  H — ,  aged  three  months, 
very  much  emaciated,  being,  according  to  the  mother's 
account,  smaller  than  at  birth.  Snuffles,  and  has  snuffled 
since  she  was  born.  Skin  shrivelled  and  parchment-like, 
covered  with  pemphigus."  Under  treatment  the  spots 
disappeared,  and  the  child  at  first  seemed  improving ;  but 
she  afterwards  sank  and  died,  having  persistently  wasted 
since  birth. 

The  second  twin  was  seen  on  the  day  the  first  died. 
A  very  healthy-looking  child,  with  good  complexion,  fat 
and  vigorous.    She  has  snuffled  since  birth,  and  on  the 
buttocks  are  seen  stains  left  by  recent  eruption.  Was 
never  thought  sufficiently  ill  to  require  medical  advice." 

These  two  cases  of  twins  suffering  from  the  same  here- 
ditary disease  are  very  interesting,  as  showing  that  the 
amount  of  disease  inherited  by  the  foetus  in  the  womb  is 
not  determined  solely  by  the  amount  of  disease  from  which 
the  parents  may  be  suffering  at  the  time.  Some  other 
causes  must  also  operate.  In  the  case  of  twins  born  of 
healthy  parents  we  often  find  one  to  be  more  vigorous 
than  the  other,  and  it  often  happens  that  one  will  sink  and 
die  while  the  other  remains  strong  and  robust.  So  in  the 
case  of  the  inheritance  of  a  constitutional  disease,  if  the 
twins  are,  while  in  the  womb,  of  unequal  vigour,  the  one 
drawing  to  itself  a  greater  proportion  of  nutritive  material 


200 


INHERITED  SYPHILIS 


than  the  other,  the  less  vigorous  foetus  would  no  doubt 
have  a  less  degree  of  resisting  power,  and  would  suffer  to  a 
greater  extent  than  the  other  from  the  effects  of  a  poison 
to  which  both  are  equally  exposed. 

When  the  child  is  born  perfectly  healthy,  he  may  still 
be  infected  after  birth.  He  may  contract  the  disease 
during  lactation,  the  nipple  of  the  mother  or  nurse  having 
become  the  seat  of  a  syphilitic  sore  from  contact  with  the 
mouth  of  another  child  who  is  suffering  from  the  disease. 
Whether  the  milk  of  a  syphilitic  woman  is  capable  alone 
of  communicating  the  disease  to  a  healthy  child  is  open  to 
very  considerable  doubt.  Again,  accidental  contact  with 
purulent  matter  from  a  chancre,  or  with  discharges  from  a 
secondary  sore,  may  inoculate  the  child ;  but  whether  the 
inoculating  matter  be  primary  or  secondary,  the  sore  thus 
produced  in  the  child  is  always  primary. 

With  regard  to  the  possibility  of  syphilitic  inoculation 
by  vaccination,  which  was  long  denied,  there  is  no  doubt, 
from  authentic  cases  which  have  been  published,  that  the 
virus  has  been  transmitted  by  this  means.  Every  case, 
however,  in  which  the  symptoms  appear  after  vaccination 
must  not  be  necessarily  attributed  to  inoculation  by  tainted 
lymph.  The  first  manifestation  of  the  latent  disease  may 
be  determined  by  anything  which  sets  up  a  temporary 
febrile  disturbance,  and  vaccination,  therefore,  may,  like 
other  things,  be  the  stimulus  exciting  the  outbreak  of 
previously  existing  disease. 

Direct  inoculation  by  a  primary  sore  in  the  vagina  during 
delivery,  although  possible,  is  not  probable,  and  no  well- 
authenticated  instance  of  such  inoculation  having  occurred 
has  been  recorded. 

Prognosis. — As  a  rule  prognosis  becomes  more  favourable 
with  each  succeeding  pregnancy.  This  rule,  however,  is 
not  absolute.  Cases  occasionally  occur  where  the  opposite 
conditions  are  found.  Thus  a  man  who  has  contracted 
the  disease  before  marriage,  and  has  undergone  suitable 


PROGNOSIS 


201 


treatment,  may  at  first  beget  a  perfectly  healthy  child. 
Afterwards,  however,  although  no  fresh  symptoms  have 
appeared  in  the  interval,  he  may  beget  other  children  who 
are  syphilitic.  There  is  no  doubt  that  mercurial  treat- 
ment has  the  power  of  rendering  the  poison  of  syphilis 
inactive  for  a  time,  and  that  in  cases  where  the  virus  is 
still  unexhausted  it  may  lie  dormant  until  time  has  lessened 
the  influence  of  the  remedy.  Such  cases  are,  however,  ex- 
ceptional and  rare.  If  we  have  noticed  a  gradual  improve- 
ment in  successive  pregnancies,  so  that  a  woman  who  had 
borne  children — at  first  prematurely,  then  stillborn  at  the 
full  time,  afterwards  living  but  diseased — bears  a  child  who 
has  at  first  the  appearance  of  health,  we  may  reasonably 
infer  that  each  succeeding  infant  has  a  better  chance  than 
its  predecessor  of  outliving  the  disease.  As  a  rule,  the 
longer  the  time  which  elapses  between  the  birth  of  a  child 
and  the  appearance  of  the  first  symptoms  the  greater  is  the 
likelihood  of  his  recovery.  When  the  symptoms  appear 
during  the  first  two  weeks  of  life  the  disease  is  almost 
always  fatal. 

It  is  to  the  intensity  of  the  general  cachexia,  and  not  to 
the  severity  of  any  particular  symptom,  that  we  must  look 
in  order  to  estimate  the  amount  of  danger  in  each  case. 
The  prognosis  is  serious  in  proportion  to  the  degree  to 
which  nutrition  is  interfered  with,  and  therefore  anything 
which  tends  to  increase  this  defect  in  nutrition  tends 
greatly  to  increase  the  gravity  of  the  case.  Thus  vomiting 
and  diarrhcea  add  their  own  enfeebling  effects  to  the 
general  weakening  influence  of  the  original  disease,  and, 
where  they  occur,  must  be  looked  upon  as  very  serious 
complications. 

There  is,  however,  one  special  symptom  which  it  is  very 
important  to  take  into  consideration  in  forming  a  prog- 
nosis, as  it  may  indirectly  produce  very  serious  results. 
This  is  the  condition  of  the  nasal  passages.  These  pas- 
sages may  become  completely  blocked  up,  jDartly  by  the 


202 


INHERITED  SYPHILIS 


swelling  of  the  Sclineiderian  membrane,  partly  by  the 
caking  of  the  crusts  formed  by  the  dried  discharge.  Two 
dangers  may  arise  from  this  source.  As  air  can  no  longer 
pass  through  the  nose,  the  mouth  becomes  the  only 
channel  by  which  air  can  be  admitted  into  the  lungs.  It 
is  therefore  required  for  respiration,  and  cannot  be  spared 
for  any  other  purpose.  The  child  is  consequently  pre- 
vented almost  entirely  from  taking  nourishment,  for  while 
he  sucks  respiration  has  necessarily  to  be  suspended.  He 
can  only  take  the  breast  by  short  snatches,  and  the  amount 
of  milk  he  receives  is  very  inadequate  to  his  wants.  The 
danger  of  starvation  is  thus  added  to  the  other  dangers 
of  the  case,  and  may  exercise  a  very  unfavourable  influence 
upon  the  termination  of  the  disease.  A  second  danger  re- 
sulting from  the  condition  of  the  nose  is  that  arising  from 
absorption  of  the  noxious  gases  produced  by  decomposition 
of  the  pent-up  pus.    Septicaemia  may  occur  in  this  way. 

On  the  whole,  we  may  conclude  that  if  nutrition  appears 
to  be  well  performed,  i.  e.  if  the  child  continues  plump,  or 
does  not  sensibly  emaciate,  the  prognosis  is  favourable.  If 
he  wastes,  the  prognosis  is  highly  unfavourable. 

Prevention. — When  a  child  is  born  suffering  from 
syphilis,  measures  should  always  be  adopted  to  prevent 
succeeding  children  from  falling  victims  to  the  same 
disease.  One  or  both  parents  should  be  subjected  to 
suitable  treatment,  which  should  be  continued  sufficiently 
long  to  render  it  probable  thai  the  next  child  will  escape 
the  effects  of  the  virus.  Even  if  a  second  pregnancy  have 
already  occurred  before  any  treatment  is  adopted,  we 
should  still  not  despair,  for  cases  are  recorded  which 
show  that  very  favourable  results  may  be  obtained  by  this 
means.  It  is  important,  however,  that  the  treatment  be 
begun  as  early  as  possible,  and  be  continued,  if  it  can  be 
borne,  for  three  full  months. 

Treatment. — In  the  treatment  of  syphilitic  children  we 
have  two  objects.    We  have  to  destroy  the  cachexia  which 


TREATMENT 


203 


is  weighing  upon  the  child,  and  we  have  to  sustain,  and  if 
possible  to  improve,  the  general  nutrition  of  the  body. 
The  second  of  these  objects  is  to  some  extent  effected  by 
the  same  means  which  accomplishes  the  first.  As  the 
intensity  of  the  cachexia  diminishes,  nutrition  usually 
improves  in  equal  proportion ;  and,  therefore,  in  the 
milder  cases  a  child  is  often  found,  as  the  symptoms 
disappear,  to  become  strong  and  healthy  under  no  other 
treatment  than  that  required  for  attacking  the  trans- 
mitted taint.  In  the  severer  cases,  however,  nutrition  is 
so  lowered  that  after  the  cause  of  the  malnutrition  has 
been  removed  special  means  must  be  adopted  to  neutralise 
its  effects. 

Treatment  must  be  begun  directly  any  symptoms  appear 
to  indicate  the  disease  from  which  the  infant  is  suffering. 
If  the  previous  children  have  been  syphilitic,  a  careful 
watch  should  be  kept  over  the  infant,  and  the  first  sign  of 
the  disease  should  be  the  signal  for  active  interference. 

The  treatment  consists  in  giving  a  preparation  of  mercury 
either  directly  to  the  child  himself  or  indirectly  through 
the  mother.  In  the  latter  case,  as  the  remedy  is  conveyed 
by  the  breast-milk,  the  method  can  only  be  resorted  to  when 
the  mother  is  nursing  her  baby,  and  has  herself  shown  sym- 
ptoms of  the  complaint.  But  even  when  it  can  be  employed 
this  method  of  treatment  is  rarely  satisfactory.  In  a 
diseased  mother  the  supply  of  milk,  as  a  rule,  is  scanty 
and  poor,  so  that  the  drug  reaches  the  infant  in  too  minute 
quantity  to  be  of  much  curative  value.  It  follows,  there- 
fore, that  when,  as  often  happens,  the  symptoms  are  severe, 
and  we  wish  to  bring  the  system  as  quickly  as  possible 
under  the  influence  of  the  remedy,  we  have,  in  addition,  to 
give  mercury  directly  to  the  child. 

For  this  purpose  the  preparation  which  is  most  com- 
monly employed  is  the  ordinary  Hydrargyrum  cum  Cretri. 
Of  this,  one  grain  may  be  given  at  first  every  morning  and 
evening.    After  the  first  week  the  dose  should  be  gradually 


204 


INHERITED  SYPHILIS 


increased  every  three  days  bj  a  quarter  of  a  grain  at  a 
time,  until  two  grains  are  taken  twice  a  day.  To  prevent 
any  irritating  action  on  the  alimentary  canal,  a  grain  of 
carbonate  of  potash,  or  a  few  grains  of  prepared  chalk, 
may  be  added  to  each  dose.  If,  in  spite  of  this  addition, 
any  disturbance  of  the  stomach  or  bowels  be  excited  by  the 
drug,  the  remedy  should  be  omitted  for  a  day  or  two 
until  this  derangement  has  subsided ;  it  must  then  be 
recommenced.  Should  the  disturbance  return,  the  grey 
powder  must  be  changed  for  one  of  the  other  preparations 
of  mercury.  A  solution  of  corrosive  sublimate  is  a  very 
convenient  form  in  which  to  administer  the  remedy,  and  if 
given  in  moderate  doses  does  not  appear  to  exercise  any 
specially  irritating  influence  upon  the  gastric  mucous 
membrane.  Most  infants  will  take  twenty  drops  of  the 
pharmacopoeia  solution  without  inconvenience  three  times 
in  the  day.  It  may  be  sweetened  with  syrup.  After  the 
first  week  the  quantity  given  should  be  gradually  increased, 
if  the  medicine  is  well  borne.  Calomel  in  doses  of  from 
one  twelfth  to  one  sixth  of  a  grain  is  sometimes  employed, 
and  where  vomiting  has  been  excited  by  the  other  prepara- 
tions, is  occasionally  effectual  in  calming  the  irritability  of 
the  stomach  ;  but  it  is  itself  liable  to  be  attended  with 
diarrhoea,  and  can  seldom  be  continued  long  without  this 
danger. 

Besides  being  given  by  the  mouth,  mercury  may  be  also 
employed  externally,  so  as  to  be  absorbed  by  the  skin,  and 
this  method  forms  a  useful  addition  to  the  other  modes 
of  treatment.  In  cases  where  the  internal  use  of  mercury 
causes  great  disturbance,  very  valuable  results  are  often 
obtained  by  this  means,  which  allows  of  the  treatment 
being  continued  while  time  is  given  for  the  irritation  of 
the  alimentary  canal  to  subside.  Still,  mercurial  frictions 
and  baths  do  not  always  act  as  safeguards  against  gastro- 
intestinal derangements.  The  frictions  are  made  with 
Unguentum  Hydrargyri,  half  a  drachm  of  which  is  rubbed 


TREATMENT 


205 


into  the  sides  of  the  chest  once  a  day  ;  or  a  flannel  band 
smeared  with  the  ointment  may  be  applied  ronnd  the  chest 
or  belly.  For  the  baths,  corrosive  sublimate  is  used,  each 
bath  containing  half  a  drachm  of  the  salt.  This  quantity 
may  be  gradually  increased,  by  fifteen  grains  at  a  time,  to 
a  drachm,  or  a  drachm  and  a  half.  The  baths  should  be 
used  every  two,  three,  or  four  days,  unless  erythema  be 
produced  by  their  employment,  when  the  quantity  of  the 
sublimate  should  be  reduced,  or  the  interval  between  suc- 
cessive baths  should  be  increased.  Besides  the  effect  upon 
the  system  produced  by  the  absorption  of  the  mercurial 
salt,  the  baths  are  also  beneficial  by  their  local  action  upon 
the  cutaneous  lesions. 

Of  the  different  ways  of  treating  the  disease  thus  de- 
scribed, we  must  employ  one  or  another,  or  several  together, 
according  to  the  condition  of  the  infant.  The  more  intense 
the  cachexia — i.  e.  the  more  complete  the  hindrance  to 
nutrition — the  more  important  does  it  become  to  bring  the 
system  as  quickly  as  possible  under  the  influence  of  the 
drug ;  but,  unfortunately,  it  is  in  these  cases  that  the  sus- 
ceptibility of  the  stomach  and  bowels  to  the  irritating 
action  of  remedies  reaches  its  height.  Here,  then,  the  ex- 
ternal plan  of  treatment  becomes  of  extreme  importance, 
and  it  must  be  aided  by  the  cautious  administration  of 
mercury  by  the  mouth,  changing  from  one  preparation  to 
another  as  circumstances  seem  to  require  it. 

At  the  same  time  every  effort  must  be  made  to  improve 
general  nutrition.  The  feeding  of  the  infant  is  a  point 
of  extreme  importance,  and  the  quality  of  his  food  must 
be  regulated  with  the  utmost  care.  Weakened  as  he  is 
by  his  constitutional  complaint,  the  child's  digestive  power 
is  small.  If  possible,  therefore,  he  should  be  brought  up 
at  the  breast ;  but,  unfortunately,  the  disease  is  one  in 
which  we  are  too  often  deprived  of  this  resource,  as  the 
mother's  milk  is  usually  scanty  or  poor.  Still,  she  should 
be  urged  to  make  every  effort  to  nurse  her  infant,  for  in 


206 


INHERITED  SYPHILIS 


his  unhealthy  state  it  is  better  that  he  be  partially  suckled 
than  brought  up  entirely  by  hand.  Whether  or  not  he  is 
to  rely  solely  for  his  nourishment  upon  his  mother's  breast 
depends  upon  the  satisfying  qualities  of  her  milk.  The 
child  must  be  carefully  watched,  and  if  he  seem  discon- 
tented after  taking  the  breast,  require  to  be  nursed  often, 
and  show  frequent  signs  of  hunger,  it  will  be  necessary  to 
make  some  addition  to  his  food.  The  breast  should  be  then 
limited  to  two  meals  a  day,  and  in  the  interval  the  diet  can 
be  regulated  in  accordance  with  the  rules  laid  down  for 
such  cases  (see  Chapter  XI,  Diet  3).  When  the  breast- 
milk  is  thus  supplemented  by  hand-feeding  in  a  delicate 
child,  we  must  remember  that  variety  in  the  food  is  an  aid 
to  digestion  which  it  would  be  unwise  to  disregard. 

Cod-liver  oil  is  often  of  great  service  in  these  cases. 
Five  or  ten  drops  may  be  given  two  or  three  times  a  day, 
in  a  spoonful  of  the  milk  and  barley-water,  and,  if  this  is 
well  borne,  the  quantity  may  be  gradually  increased  by  a 
drop  or  two  at  a  time.  If,  however,  it  causes  sickness  or 
uneasiness  it  must  be  stopped  at  once,  to  be  returned  to 
after  a  few  days,  and  in  smaller  doses.  If  any  of  the  oil 
appears  unchanged  in  the  stools  the  quantity  must  be  re- 
duced. The  child  must  be  kept  in  an  equable  temperature 
of  from  60°  to  65*^  Fahr.,  partly  in  order  to  avoid  the  risk 
of  cold,  to  which  he  is  particularly  susceptible  while  under 
the  influence  of  mercury ;  partly  on  account  of  the  bene- 
ficial influence  upon  the  disease  of  a  moderately  high 
temperature,  for  all  writers  upon  this  subject  unite  in  re- 
commending warmth  as  an  important  aid  to  the  other 
treatment. 

The  utmost  cleanliness  must  be  observed.  After  taking 
food  the  mouth  should  be  carefully  washed  out  with  a 
piece  of  linen  rag  dipped  in  warm  water,  to  prevent  any 
accumulation  of  milk  round  the  gums  and  cheeks— a 
fruitful  source  of  thrush.  The  napkins  must  be  changed 
frequently,  and  the  buttocks  be  carefully  sponged  and 


TREATMENT  OF  COMPLICATIONS 


207 


dried  after  each  action  of  the  bowels,  for  all  unnecessary 
irritation  of  the  skin  must  be  avoided,  and  the  continued 
contact  of  the  urine  and  stools  with  the  skin  promotes 
the  occurrence  of  the  specific  erythema.  Besides,  cleanli- 
ness is  important  in  promoting  the  healing  of  mucous 
patches  and  other  syphilitic  sores  about  the  anus.  For 
the  same  reason  the  whole  body  should  be  bathed,  at  least 
once  a  day,  with  warm  water,  care  being  taken  to  dry  the 
child  thoroughly  after  each  ablution. 

If  vomiting  occur,  the  internal  use  of  mercury  must 
be  suspended;  and  should  the  gastric  disturbance  still 
continue,  the  child's  nourishment  must  be  limited  to  his 
mother's  milk.  If  the  vomiting  does  not  subside  by  this 
means,  all  food  must  be  forbidden,  and  the  child  be 
allowed  nothing  but  cold  barley-water,  given  at  intervals 
with  a  teaspoon.  These  measures  usually  succeed  in 
arresting  the  vomiting,  and,  in  most  cases,  the  mere  sus- 
pension of  the  mercury  is  sufficient  to  produce  this  result. 
Should  it,  however,  continue,  a  hot  linseed-meal  poultice 
containing  a  sixth  part  of  mustard  must  be  applied  to  the 
epigastrium,  and.  one  sixth  of  a  grain  of  calomel,  with  a 
few  grains  of  powdered  chalk,  must  be  given  every  four 
hours  ;  or  a  mixture  containing  three  grains  of  bicarbonate 
of  soda  to  a  teaspoonful  of  infusion  of  calumba  may  be 
ordered  three  times  a  day.  When  the  vomiting  is  obsti- 
nate, the  case  becomes  one  of  great  danger. 

Diarrhoea  is  best  treated  by  suspending  the  mercurial, 
and  if  this  is  not  followed  by  stoppage  of  the  disorder,  a 
mixture  of  chalk  and  catechu,  with  aromatic  confection, 
is  usually  sufficient  to  restore  the  bowels  to  their  natural 
condition.  Diarrhoea  is  seldom  obstinate  in  this  disease 
if  the  directions  already  given  as  to  diet  and  avoidance  of 
cold  have  been  properly  attended  to. 

In  cases  where  either  of  these  symptoms  has  occurred 
great  caution  is  necessary  in  returning  to  the  specific  treat- 
ment, giving  the  mercury  in  smaller  doses,  and  assisting  it 


208 


INHERITED  SYPHILIS 


by  the  external  application  of  that  drug,  either  in  the  form 
of  baths  or  ointment. 

Local  applications  are  useful  as  aids  to  the  specific 
treatment  in  furthering  the  disappearance  of  the  local 
lesions.  It  is  important  to  remove  these  local  symptoms 
as  quickly  as  may  be,  for  although  many  of  them  do  not 
sensibly  affect  the  prognosis,  yet  others,  as  the  condition 
of  the  nose,  may  exercise  an  unfavourable  influence  on 
the  termination  of  the  disease.  Besides,  so  long  as  there 
are  contagious  sores  upon  the  body  of  the  child,  his 
attendants  may  possibly  become  infected  by  direct  con- 
tagion, and  this  danger  should  be  removed  as  promptly 
as  possible.  In  the  third  place,  a  healthy  skin  is  indis- 
pensable to  the  successful  employment  of  frictions,  either 
with  the  mercurial  ointment  or  with  cod-liver  oil. 

The  baths  of  corrosive  sublimate  have,  as  has  already 
been  stated,  a  very  favourable  influence  upon  the  cutaneous 
lesions,  but  there  are  other  special  applications  which  may 
be  made  use  of  in  treating  these  affections. 

When  the  nostrils  become  blocked  up  by  hard  crusts, 
these  latter  should  be  gently  removed,  after  being  softened 
by  warm  water  and  cold  cream.  When  the  internal  sur- 
face is  thus  laid  bare,  a  little  mercurial  ointment  may  be 
gently  applied  to  the  mucous  membrane  lining  the  nostrils 
with  a  feather,  or  with  a  piece  of  linen  rag  rolled  up  into 
the  form  of  a  slender  cylinder.  A  useful  ointment  for  this 
purpose  is  composed  of  XJng.  Hyd.  Am.  Chlor.,  Ung.  Zinci, 
and  Ung.  Acidi  Borici  in  equal  proportions. 

Large  crusts  formed  on  the  body  should  be  removed  by 
covering  them  with  a  thick  layer  of  lard,  and  laying  over 
this  a  hot  bread-and-water  poultice.  This  should  be 
applied  at  night,  and  in  the  morning  the  softened  scab 
can  be  easily  detached,  and  the  ulcer,  when  exposed,  must 
be  touched  with  the  solid  nitrate  of  silver. 

Mucous  patches  about  the  mouth  or  anus  must  be  well 
touched  with  the  same  caustic.    They  must  be  kept  very 


AFTER  TREATMENT 


209 


clean  as  previously  directed.  Ricord  orders  the  patches 
to  be  washed  twice  a  day  with  a  solution  of  chloride  of 
soda,  and  after  each  washing  a  small  quantity  of  calomel 
is  to  be  applied  with  pressure. 

Mercurial  treatment  must  not  be  continued  too  long, 
for  the  prolonged  administration  of  this  drug  to  young 
children  produces  a  condition  of  intense  anaemia  which 
often  persists  long  after  the  remedy  has  been  abandoned. 
It  is  better  not  to  continue  specific  treatment  after  the 
symptoms  have  disappeared.  Afterwards  it  is  advisable 
to  give  a  tonic,  as  a  mineral  acid  with  bitter  infusion, 
quinine,  iron,  cod-liver  oil,  &c.  Iodide  of  iron  is  valuable 
in  these  cases,  but  it  is  best  given,  not  in  the  form  of  the 
syrup,  but  by  combining  iodide  of  potassium  with  tartrate 
of  iron  in  distilled  water.  This  combination  makes  a 
perfectly  clear  solution,  and  is  much  preferred  for  children 
on  account  of  the  tendency  of  the  pharmacopoeia  syrup  to 
set  up  fermentation  and  give  rise  to  acidity. 


14 


CHAPTER 


VI 


MUCOUS  DISEASE 

MUCOUS  disease,  a  very  frequent  disorder  amongst 
children,  may  be  met  with  at  any  age,  but  is  most 
common  between  three  or  four  and  ten  or  twelve  years. 
The  derangement  consists  in  an  increased  secretion  of 
mucus  from  the  whole  internal  surface  of  the  alimentary 
canal;  it  is  a  mucus  flux  which  interferes  mechanically 
with  digestion  and  absorption  of  the  food,  and  by  its  in- 
fluence in  impeding  general  nutrition  often  excites  sus- 
picions of  the  existence  of  tubercle. 

The  symptoms  vary  in  intensity  according  to  the  degree 
to  which  nutrition  is  interfered  with.  At  first  they  are 
usually  slight,  but  become  more  severe  as  the  derangement 
becomes  more  marked.  Thus  the  child  gets  languid  and 
dull,  he  is  disinclined  to  exertion,  and  complains  of 
weariness  and  depression.  He  grows  pale  and  loses  flesh ; 
his  spirits  are  low ;  he  ceases  to  take  interest  in  his 
accustomed  amusements,  and  sits  listless  and  moody, 
sometimes  crying  without  apparent  cause.  He  is  often 
drowsy  in  the  day,  but  is  restless  at  night,  grinding  his 
teeth ;  and  his  sleep  is  often  disturbed  by  frightful  dreams, 
from  which  he  wakes  in  great  terror,  crying  and  talking 
incoherently.  The  conduct  of  the  child  at  night  is  often 
extremely  perplexing  to  his  relatives.  Sometimes  he  will 
start  from  his  sleep  with  a  loud  cry,  and  will  remain  for  a 
considerable  time  under  the  influence  of  the  most  violent 
panic,  uttering  wild  exclamations,  and  being  apparently 
unable  to  recognise  the  familiar  faces  of  those  who  are 


SYMPTOMS 


211 


endeavouring  to  soothe  him.  At  other  times  he  will  rise 
from  his  bed  still  asleep,  and  will  walk  from  room  to  room. 
In  fact,  most  of  the  cases  of  somnambulism  in  children 
are  due  to  this  cause.  IsTocturnal  incontinence  of  urine  is 
also  not  unfrequently  complained  of,  and  this,  although  in 
the  beginning  only  occasional,  may  afterwards  become 
habitual. 

Many  other  signs  of  nervous  uneasiness  may  often  be 
observed.  As  a  rule,  the  child  is  excessively  irritable  and 
peevish.  He  is  unreasonably  exacting  in  the  nursery, 
quarrels  with  his  brothers  and  sisters,  and  may  fall  into 
violent  fits  of  rage  at  the  most  trifling  annoyance.  His 
mother  will  say  that  he  has  become  so  naughty  she  cannot 
think  what  has  come  to  the  child."  In  the  worst  cases 
other  nervous  derangements  may  occur,  such  as  squinting 
and  stammering.  The  latter  symptom  is  usually  found  to 
vary  in  degree  according  to  the  intensity  of  the  general 
symptoms,  and,  unless  it  has  persisted  sufficiently  long  to 
lead  to  an  acquired  habit,  usually  passes  off  as  the  de- 
rangement subsides. 

The  appetite,  at  first  unusually  keen,  becomes  gradually 
capricious,  then  fails  almost  entirely ;  and  each  meal  is 
followed  after  some  little  interval  by  flatulence  and  un- 
easiness. The  appetite  may,  however,  remain  large,  even 
after  the  emaciation  has  become  extreme,  and  in  some 
cases  the  hunger  seems  almost  insatiable,  the  child  very 
shortly  after  a  full  meal  asking  again  for  food. 

The  tongue  is  generally  flabby  and  indented  at  the  edges 
by  the  teeth,  but  it  has  besides  a  peculiar  appearance, 
which  is  very  characteristic.  This  appearance  is  due  to  the 
mucus  with  which  it  is  covered,  for  the  glands  of  the  mouth 
are  as  active  in  their  secretion  as  those  of  the  other  parts 
of  the  alimentary  canal.  A  glossy,  slimy  look  is  thus 
given  to  the  organ,  which  is  quite  distinct  from  the  moist 
appearance  produced  by  saliva  alone,  and  resembles  more 
the  aspect  it  would  bear  if  brushed  over  with  a  solution  of 


212 


MUCOUS  DISEASE 


gum.  This  slimj  look  is  not  always  general,  but  in  sliglitly 
marked  cases  is  limited  to  a  spot  in  the  centre  of  the 
dorsum,  the  rest  of  the  surface  and  the  sides  having  the 
ordinary  aspect.  The  tongue  is  either  perfectly  clean, 
or  is  covered  with  a  thin  coating  of  grey  fur.  The  fungi- 
form papillae  at  the  sides  of  the  dorsum  are  also  unusually 
distinct.  They  are  seen  as  large  round  or  oval  spots, 
seldom  elevated,  and  varying  in  colour  from  pale  red  to 
deep  crimson  ;  the  depth  of  colour  being  in  proportion  to 
the  degree  of  irritability  of  the  digestive  organs.  If 
vomiting  or  diarrhoea  supervene,  their  colour  becomes 
bright  red,  and  they  then  project  slightly  above  the  surface, 
peering  through  the  thick  coating  of  yellow  fur  with  which 
the  dorsum  in  such  cases  is  usually  covered.  Sometimes  a 
different  appearance  is  presented,  and  the  whole  tongue  is 
clean,  with  a  glazed  glossy  look,  as  if  entirely  denuded  of 
epithelium. 

The  bowels  may  act  regularly  or  be  more  or  less  costive. 
In  the  latter  case  there  is  some  straining  at  stool,  and 
light- coloured,  pasty  motions  are  evacuated,  mixed,  per- 
haps, with  strings  or  lumps  of  free  mucus.  Even  when 
the  stools  do  not  contain  mucus  habitually,  it  is  common 
for  large  quantities  of  the  secretion  to  be  brought  away  by 
the  action  of  a  mild  aperient.  Sometimes  we  find  consti- 
pation and  diarrhoea  to  alternate  with  one  another.  Thus 
the  bowels  are  obstinate  for  two  or  three  days,  or  even  for 
a  whole  week ;  a  violent  fit  of  purging  then  sets  in,  with 
ten,  twelve,  or  even  more  stools  in  the  twenty -four  hours  ; 
after  which,  the  accumulation  having  been  discharged,  the 
bowels  become  again  confined. 

There  is  often  an  unpleasant  smell  from  the  mouth  of 
the  child,  probably  due  to  catarrh  of  the  oral  mucous 
membrane,  and  decomposition  of  the  mucus  and  epithe- 
lium. In  some  cases,  however,  it  is  evidently  dependent 
upon  enlarged  tonsils,  which  secrete  a  thick,  bad- smelling 
semi-purulent  matter. 


SYMPTOMS 


213 


The  colour  of  the  face  undergoes  rapid  changes.  There 
is  usually  some  discoloration  under  the  eyes,  but  a  cha- 
racteristic symptom  is  sudden  pallor,  the  child  seeming  as 
if  about  to  faint.  To  use  the  nurse's  expression,  "he 
turns  deadly  white,"  and  his  ghastly  apj^earance  at  this 
time  often  excites  comment.  Sometimes  actual  syncope 
occurs,  for  fainting  fits  are  not  an  uncommon  symptom  of 
the  derangement. 

The  complexion  is  often  remarkably  sallow,  having  a 
half -jaundiced  tint ;  and  this  varies  in  degree  from  day 
to  day,  the  colour  being  most  dingy  at  the  time  when  the 
nervous  symptoms  are  most  strongly  marked.  Thickness 
or  muddiness  of  the  complexion  is  often  associated  with 
acidity  of  urine  and  a  free  precipitation  of  urates.  At 
these  times,  too,  the  child  is  apt  to  complain  of  headache, 
or  of  flatulent  pains  about  the  chest  or  belly.  A  stitch 
in  the  side  is,  indeed,  a  common  source  of  annoyance. 
When  asked  to  point  out  the  seat  of  pain,  the  patient 
almost  always  places  his  hand  over  the  left  hypochon- 
drium.  It  will  be  remembered  that  the  large  bowel  at 
this  spot  makes  a  very  abrupt  bend,  and  the  angle  thus 
formed  is  a  common  seat  for  the  accumulation  of  flatus. 

Abdominal  pains  of  a  paroxysmal  character  are  some- 
times met  with.  These  are  seated  about  the  umbilicus. 
They  are  apt  to  come  on  in  the  early  morning,  before 
rising  from  bed,  and  are  sometimes  excited  by  taking  food. 
They  do  not,  as  a  rule,  cause  any  feeling  of  nausea ;  nor 
are  they  followed  by  looseness  of  the  bowels  ;  nor  is  there 
any  tendency,  as  in  ordinary  colic,  to  seek  relief  by  bending 
the  body.  If  the  pains  are  very  severe,  the  child  may  be 
noticed  to  turn  white. 

In  some  children  the  skin  ceases  to  act  at  a  very  early 
stage  of  the  disease,  and  becomes  rough  and  harsh,  espe- 
cially about  the  chest,  arms,  and  belly.  In  extreme  cases 
the  whole  body  may  be  covered  with  little  scales  of  epi- 
thelium, which  can  be  rubbed  oH  as  fine  dust. 


214 


MUCOUS  DISEASE 


The  lymphatic  glands  of  the  neck  are  liable  to  become 
enlarged  on  the  slightest  irritation.  They  do  not,  how- 
ever, necessarily  suppurate  or  remain  permanently  swollen. 
The  enlargement,  after  persisting  for  a  variable  time,  may 
disappear  completely. 

The  temperature  of  the  body  is  not  raised.  Often  it  is 
lowered,  especially  at  the  surface,  and  a  prominent  sym- 
ptom is  the  extreme  coldness  of  the  hands  and  feet.  It  is 
curious  that  the  patient  himself  usually  seems  unconscious 
of  this  peculiarity,  or  indifferent  to  its  discomfort,  and  will 
declare  that  his  feet  are  warm  when  examination  shows 
them  to  be  quite  the  contrary.  'Not  seldom  from  morning 
to  night,  and  even  after  the  child  has  been  put  to  bed,  his 
feet  remain  in  the  same  cold,  clammy  state. 

The  symptoms  thus  described  do  not  proceed  in  any 
regular  manner  from  bad  to  worse.  It  is  usually  found 
that  the  child  is  subject  every  few  weeks  to  what  are 
called  "  bilious  attacks  " — to  violent  attacks,  that  is,  of 
vomiting  and  purging,  lasting  often  for  several  days, 
during  which  large  quantities  of  mucus  are  got  rid  of. 
The  system  being'  thus  relieved,  the  symptoms  become 
for  a  time  less  severe ;  the  child  sleeps  better  at  night, 
and  during  the  day  is  less  languid,  and  more  inclined  to 
take  exercise.  The  improvement  is  not,  however,  of  long 
continuance ;  for  the  symptoms  returning,  grow  gradually 
worse  until  they  culminate  in  another  violent  attack  like 
the  former.  In  this  way  the  child  may  go  on  for  months, 
gradually  getting  thinner  and  weaker,  his  condition  ex- 
citing the  gravest  apprehensions  amongst  his  relatives, 
especially  as  a  short  hacking  cough  is  a  not  unfrequent 
symptom  of  this  disorder,  and  increases  their  fears  of 
the  outset  of  consumption.  Examination  of  the  lungs, 
however,  in  an  uncomplicated  case  of  mucous  disease  will 
reveal  no  signs  of  pulmonary  mischief. 

Worms,  especially  amongst  the  poorer  classes,  form  a 
common  complication  of  this  derangement ;  in  which  case 


EFFECT  ON  NUTRITION 


215 


the  symptoms  are  all  attributed  to  the  presence  of  the 
entozoa.  The  creatures  find  in  the  alkaline  mucus  a 
congenial  nidus ;  but  the  disordered  state  of  the  mucous 
membrane  is  at  least  as  important  as  are  the  parasites 
themselves ;  and  until  the  alimentary  canal  is  restored  to 
a  more  healthy  condition,  special  anthelmintics  frequently 
fail  of  success.  The  difficulty  so  often  experienced  in 
curing  a  child  of  worms  is  due  to  neglect  of  the  measures 
necessary  effectually  to  restrain  this  unnatural  activity  of 
the  mucous  glands.  The  subject  of  worms  will,  however, 
be  more  conveniently  treated  of  in  another  chapter. 

It  is  easy  to  understand  how  nutrition  must  suffer  in 
this  disease.  The  mucus  poured  out  into  the  stomach 
and  bowels  seems  to  act  as  a  ferment,  and  to  cause  decom- 
position of  the  food  with  which  it  comes  into  contact.  The 
products  of  fermentation  are  gas  and  acid.  The  gaseous 
accumulations  excite  the  abdominal  pains  and  side- stitch 
which  are  the  source  of  so  many  complaints.  The  acid 
finding  its  way  into  the  circulation  is  distributed  through- 
out the  body,  and  by  keeping  the  tissues  in  a  state  of  con- 
tinual irritation,  is  no  doubt  a  cause  of  the  unruliness  of 
temper,  the  nocturnal  excitability,  and  the  excessive  mus- 
cular restlessness  which  form  such  prominent  features  of 
the  disorder.  In  the  alimentary  canal  the  excess  of  acid 
has  a  direct  influence  upon  the  digestion  of  food.  It  par- 
tially coagulates  the  mucus,  so  that  the  alimentary  masses 
being  coated  more  or  less  completely  by  thick  slimy  matter 
are  not  properly  mixed  up  with  the  digestive  fluids.  A 
comparatively  small  part  of  the  food  which  has  been  taken 
is  therefore  converted  into  a  form  in  which  it  is  capable 
of  being  absorbed ;  and  of  that  small  part  a  still  smaller 
is  actually  taken  up  by  the  absorbent  vessels,  on  account 
of  the  thick  layer  of  viscid  mucus  which  lines  the  walls  of 
the  bowel,  and  prevents  the  veins  and  the  lacteals  from 
performing  their  functions. 

The  large  appetite  so  commonly  found  in  these  cases 


216 


MUCOUS  DISEASE 


is,  no  doubt,  in  part,  a  manifestation  of  the  want  of 
nourishment  felt  throughout  the  system ;  but  it  is  pro- 
bably also,  in  part,  a  morbid  craving  excited  by  the  stimu- 
lating action  of  the  fermenting  contents  of  the  stomach 
and  bowels. 

Causes. — In  children  there  is  naturally  great  activity 
of  the  mucous  membrane  lining  the  alimentary  canal.  As 
compared  with  the  adult  its  secretion  appears  in  them  to 
be  always  in  excess,  and  a  very  slight  irritation  is  sufficient 
to  increase  it.  The  stools  of  young  infants  are  in  their 
natural  state  composed  in  great  part  of  mucus,  and  any 
passing  irritation,  such  as  a  meal  of  indigestible  food,  or 
a  slight  chill,  causes  at  once  a  marked  increase  of  the 
secretion ;  the  so-called  slimy  stools  are  then  passed,  con- 
sisting of  thick  viscid  mucus,  mixed  up  more  or  less 
intimately  with  the  fsecal  matter.  In  cases  where  the 
irritation  is  constantly  renewed,  as  occurs  in  children 
who  are  habitually  fed  upon  indigestible  food,  large  quan- 
tities of  mucus  are  passed,  often  coating  the  small  faecal 
masses,  or  appearing  separately  as  strings  and  jelly-like 
Lumps. 

Certain  diseases  are  apt  to  leave  behind  them  this 
condition  of  the  bowels ;  thus,  measles  and  scarlatina  may 
be  sometimes  followed  by  it.  Whooping-cough  is,  how- 
ever, of  all  diseases  the  one  to  which  this  derangement 
can  most  commonly  be  traced,  and  there  is  a  special 
reason  why  this  should  be  so.  In  whooping-cough  the 
bronchial  mucous  membrane  secretes  a  tough  stringy 
mucus  in  very  large  quantities,  and  there  is  at  the  same 
time  a  copious  mucous  flux  from  the  stomach  and  bowels. 
The  abundant  thick  mucus  which  is  vomited  at  the  termi- 
nation of  the  characteristic  cough  comes  in  great  part 
from  the  stomach  ;  and  the  involuntary  evacuations  which 
are  so  frequently  found  to  follow  a  paroxysm  contain 
much  of  the  same  secretion.  The  tongue  in  all  severe 
cases  of  whooping-cough  will  be  found  to  correspond 


CAUSATION 


217 


exactly  with  the  appearance  of  the  organ  described  as 
characteristic  of  mucous  disease ;  in  fact,  an  acute  attack 
of  this  intestinal  derangement  is  a  constant  accompani- 
ment of  severe  jDcrtussis.  As  the  whooping-cough  lessens 
in  severity,  the  derangement  of  the  alimentary  canal 
frequently  subsides ;  but  in  many  cases,  especially  if  the 
child  be  weakly  or  be  much  reduced  by  the  intensity  or  the 
long  continuance  of  the  disease,  the  flux  from  the  bowels 
continues  and  becomes  a  chronic  condition.  It  is  for  this 
reason  that  whooping-cough  is  so  much  to  be  dreaded  in 
weakly  children.  The  disease  not  only  interferes  with 
nutrition  while  actually  in  progress,  but  also  leaves  behind 
it  a  chronic  derangement  of  the  bowels  which  often  pro- 
duces extreme  emaciation,  and  may  favour  the  occurrence 
of  very  serious  complications. 

An  explanation  of  the  persistence  of  the  digestive  trouble 
is,  I  believe,  to  be  found  in  the  extreme  susceptibility  of 
the  subjects  of  mucous  disease  to  alternations  of  tempera- 
ture. With  hands  and  feet  habitually  cold,  a  child  can 
have  little  power  of  resisting  the  effects  of  chill;  and, 
indeed,  I  have  often  noticed  that  any  sudden  change  of 
weather,  or  the  mere  going  out  with  cold  feet  into  a  raw 
air,  has  been  followed  by  a  return  of  the  worst  symptoms 
of  the  complaint.  Owing  to  these  slight  but  repeated 
chills,  the  stomach  and  bowels  are  kept  in  a  state  of  con- 
tinual catarrh ;  and  the  attacks  of  vomiting  and  purging 
may  very  possibly  be  nothing  more  than  acute  attacks  of 
gastro-intestinal  catarrh  induced  by  some  exceptional  ex- 
posure to  cold  or  damp. 

The  commencement  of  the  second  dentition  is  a  time  at 
which  this  derangement  is  especially  likely  to  be  set  up. 
Children  are  often  found,  as  the  early  teeth  begin  to  be 
displaced  by  the  second  crop,  to  grow  pale,  and  thin,  and 
languid ;  indeed,  so  frequently  is  this  found  to  occur,  that 
the  beginning  of  the  second  dentition  is  looked  upon  as 
one  of  the  critical  periods  of  early  life.    There  is  no  doubt 


218 


MUCOUS  DISEASE 


that,  owing  to  the  intimate  sympathy  existing  between  all 
parts  of  the  alimentary  canal,  there  is  at  the  time  of  denti- 
tion a  great  tendency  to  an  increased  activity  of  secreting 
function  and  an  increased  susceptibility  to  disturbing 
influences. 

Diagnosis. — In  a  well-marked  case  the  symptoms  of  this 
derangement  present  a  remarkable  resemblance  to  those  of 
tuberculosis,  with  which  it  is  so  often  confounded;  the 
distinguishing  points  between  the  two  diseases  are  there- 
fore of  much  importance. 

The  most  characteristic  symptoms  of  mucous  disease 
are  the  perceptible  wasting ;  the  slimy  appearance  of  the 
tongue ;  the  large  quantities  of  free  mucus  in  the  stools ; 
the  great  want  of  regularity  in  the  progression  of  the 
symptoms ;  and  the  periodical  occurrence  of  bilious  attacks. 
If  these  conditions  are  observed  to  follow  an  attack  of 
whooping-cough,  or  to  occur  at  the  time  of  the  second 
dentition  ;  if  they  are  accompanied  by  dry,  rough  skin  and 
sallow  complexion ;  and  if  the  temperature  of  the  body  is 
not  raised  above  the  natural  level,  we  may  conclude  that 
the  illness  is  due  to  the  cause  which  has  been  described. 

With  regard  to  the  heat  of  the  body,  it  must  be  remem- 
bered that  a  continued  elevation  of  temperature  is  necessary 
to  demonstrate  the  existence  of  tuberculosis.  In  mucous 
disease  the  temperature  may  be  elevated  temporarily  by 
passing  sources  of  irritation,  and  thus  may  be  found  to  be 
high  on  two  or  three  successive  days.  In  these  cases, 
therefore,  some  caution  should  be  exercised  in  making  a 
diagnosis,  and  further  observations  will  be  necessary  before 
we  can  feel  ourselves  justified  in  giving  a  positive  opinion 
upon  the  nature  of  the  disease. 

Cases,  however,  of  this  derangement  occur  in  which  the 
temperature  rises  and  remains  elevated,  perhaps  perma- 
nently, although  the  symptoms  in  other  respects  correspond 
to  those  of  mucous  disease.  Pneumonia  is  very  apt  to 
attack  such  patients,  and  it  is  not  at  all  uncommon  for 


TREATMENT 


219 


the  deposit,  remaining  entirely  or  partially  nnabsorbed, 
to  undergo  cheesy  transformation  and  form  the  so-called 
pneumonic  phthisis — one  of  the  many  varieties  of  pul- 
monary consumption.  In  such  cases  it  is  often  a  very 
nice  point  to  decide  upon  the  presence  or  absence  of  grey 
tubercle ;  but  by  careful  consideration  of  the  history  of 
the  acute  attack,  and  by  minute  observation  of  the  seat 
and  progress  of  the  physical  signs,  a  diagnosis  can  be 
generally  arrived  at  (see  diagnosis  of  pulmonary  phthisis) . 
If  the  formation  of  grey  tubercle  occur  at  all  in  such 
cases,  the  coincidence  must  be  looked  upon  as  accidental, 
for  mucous  disease  is  quite  distinct  from  the  tuberculous 
diathesis,  and  independent  of  it. 

Treatment. — For  the  cure  of  this  derangement  the 
strictest  attention  to  diet  is  indispensable.  The  morbid 
condition  to  be  overcome  is  the  excessive  secretion  of 
mucus  from  the  whole  lining  of  the  alimentary  canal ;  and 
one  of  the  most  effectual  measures  for  restraining  this 
morbid  glandular  activity  is  the  prohibition  of  all  articles 
of  diet  capable  of  undergoing  fermentation,  and  so  of 
increasing  the  irritation  of  the  mucous  membrane.  All 
farinaceous  articles  of  diet,  except  bread,  must  be,  there- 
fore, at  once  forbidden  ;  and  even  the  bread  should  be  con- 
siderably restricted  in  quantity,  and  should  be  eaten  stale, 
or  in  the  form  of  dry  toast.  Potatoes,  peas,  beans,  turnips, 
carrots,  parsnips,  beetroot,  fruit,  cakes,  and  pastry  must 
all  be  excluded  from  the  diet,  and  the  child  should  be 
nourished  as  nearly  as  possible  upon  meat,  eggs,  and  milk. 
Too  much  food  is  not  to  be  given  at  once,  for  all  over- 
loading of  the  stomach  is  to  be  avoided.  It  is  better  to 
distribute  the  amount  allowed  over  four  meals  rather  than 
three,  and  these  should  be  fixed  at  regular  intervals  through- 
out the  day. 

A  good  scale  of  diet  for  a  child  over  two  years  old  is  the 
following,  given  in  four  separate  meals  in  the  course  of 
the  day : 


220 


MUCOUS  DISEASE 


First  meal. — Fresh  milk,  diluted  with  a  third  part  of 
lime-water,  or  alkalinised  with  from  ten  to  twenty  drops 
of  the  saccharated  solution  of  lime.  A  small  slice  of  dry 
toast  or  of  dry  stale  bread  with  butter. 

Second  meal. — A  small  mutton  chop,  or  a  slice  of  roast 
mutton  or  beef.  Dry  toast  or  stale  bread.  If  the  child 
be  four  or  five  years  old  he  may  take  with  this  meal  a  little 
vegetable,  as  well-boiled  cabbage,  spinach,  or  broccoli. 

Third  meal. — A  cup  of  beef-tea  or  mutton-broth,  free 
from  grease ;  or  the  yolk  of  a  lightly-boiled  egg ;  dry 
toast. 

Fourth  meal. — A  cup  of  cocoa  made  with  milk  ;  dry 
toast  or  stale  bread  with  butter. 

It  is  not  always  easy  to  persuade  children  to  submit 
readily  to  the  deprivation  of  starchy  food,  for  which,  and 
especially  for  potatoes,  there  is  often  in  these  cases  a  great 
craving.  So  long,  however,  as  the  slimy  appearance  of 
the  tongue,  before  described,  continues  to  be  observed, 
the  above  diet  should  if  possible  be  adhered  to.  "When 
potatoes  are  once  more  allowed  they  must  be  well  boiled, 
and  should  be  afterwards  carefully  mashed  with  a  spoon. 
Gravy  may  be  poured  over  them  before  they  are  eaten.  A 
good  substitute  for  potatoes  in  these  cases  is  the  flower  of 
cauliflower  very  well  boiled.  Other  allowable  vegetables 
are  turnip-greens,  asparagus,  French  beans,  vegetable 
marrow,  Spanish  onions,  lettuce  and  celery  (stewed) .  The 
diet  may  be  varied  by  substituting  for  the  mutton  chop  a 
little  roast  chicken  or  game.  Well-boiled  turbot,  cod,  sole, 
or  mackerel  may  also  be  permitted.^ 

Alcohol  may  be  given  with  advantage  in  many  of  these 
cases,  and  where  the  strength  has  been  much  reduced  is 
of  considerable  service  in  improving  the  appetite  and 
increasing  the  digestive  power.  Half  a  glass  of  dry  sherry 
diluted  with  water  may  be  taken  at  dinner,  or  double  the 
quantity  of  light  claret  and  water. 

*  For  tabulated  diets,  see  Chapter  XI,  Diets  19,  20,  21. 


TREATMENT 


221 


When  the  derangement  has  existed  for  some  time,  and 
the  general  nutrition  of  the  body  is  much  lowered,  the 
appetite  may  fail.  In  these  cases  it  is  often  difficult  to 
persuade  the  child  to  take  nourishment,  especially  as  his 
chief  craving  is  for  bread  and  butter,  potatoes,  and  all  the 
articles  of  diet  which  are  particularly  injurious.  Meat  is 
in  these  cases  often  extremely  distasteful  to  him.  A  lark 
or  a  snipe  will,  however,  by  apj^ealing  to  his  fancy,  some- 
times overcome  this  dislike,  and  every  means  should  be 
tried,  by  varying  his  diet  within  the  prescribed  limits,  to 
induce  him  to  take  a  sufficient  quantity  of  food. 

At  the  same  time  every  effort  should  be  made  to  restore 
the  proper  action  of  the  skin.  At  night  the  child  must 
be  bathed  with  hot  water,  and  after  being  carefully  dried 
must  be  anointed  over  the  whole  body  with  warm  olive 
oil ;  this  process  to  be  repeated  regularly  every  evening 
at  bedtime.  In  cases  where  the  skin  is  especially  dry  and 
rough,  it  is  well  on  the  first  evening  to  remove  the  hardened 
epithelium  by  a  thorough  washing  with  soap,  using  hot 
water  softened  by  the  addition  of  a  handful  of  carbonate 
of  soda.  In  the  morning  the  child  should  have  a  warm 
sponge-bath.  Under  such  treatment  the  skin  will  quickly 
recover  its  natural  appearance,  and  become  soft  and  supple. 

The  child  should  be  warmly  clothed,  and  should  take 
plenty  of  exercise  in  the  open  air ;  if  the  weather  be  mild, 
almost  the  whole  day  should  be  passed  out  of  doors.  He 
should  wear  a  shirt  and  drawers  of  flannel,  or  a  pure  wool 
combination  "  garment;  and  his  belly  should  have  the 
additional  protection  of  a  broad  flannel  binder.  Moreover, 
very  special  care  should  be  taken  to  keep  the  feet  warm. 

The  above  measures — even  if  no  medicines  have  been 
given  at  all — will  after  a  very  short  time  produce  a  marked 
improvement  in  the  appearance  of  the  child.  The  stoppage 
of  starchy  food,  and  especially  of  potatoes,  will  by  itself 
remove  a  great  many  of  the  more  distressing  symptoms  ; 
the  restlessness  at  night,  in  particular,  usually  ceases  at 


222 


MUCOUS  DISEASE 


once.  There  are,  however,  certain  medicines  which  should 
not  be  neglected  ;  but  those  most  calculated  to  assist  the 
object  we  have  in  view  are  not  those  which,  under  the 
name  of  tonics,  are  usually  resorted  to  when  from  any 
cause  healthy  nutrition  of  the  body  appears  to  be  in  abey- 
ance. The  best  tonic  is  nourishing  food.  But  that  the 
food  taken  may  be  nourishing,  it  must  first  of  all  be 
digested ;  and  those  medicines  will  be  the  real  tonics 
which  enable  the  alimentary  canal  properly  to  perform  its 
functions.  Our  object,  as  has  been  before  remarked,  is  to 
check  as  rapidly  as  possible  the  excessive  secretion  of 
mucus  which  prevents  the  food  from  being  sufficiently 
mixed  with  the  digestive  fluids,  and  impedes  the  action 
of  the  absorbent  vessels.  Various  medicines  will  accom- 
plish this  result.  Thus  alkalies  not  only  appear  to  have 
an  influence  in  arresting  the  secretion  of  mucus,  but  also, 
by  at  once  neutralising  any  acid  formed  by  the  fermen- 
tation of  food,  produce  a  raj^id  change  for  the  better  in 
the  general  symptoms.  The  best  form  in  which  they  can 
be  given  is  the  bicarbonate  of  soda  with  a  bitter,  as  the 
infusion  of  calumba.  To  each  dose  may  be  added  half 
a  grain  of  iodide  of  potassium,  to  increase  the  salivary 
secretion,  and  twenty  drops  of  the  tincture  of  myrrh, 
which  is  found  to  have  a  powerful  bracing  effect  upon  the 
mucous  membrane.  The  mineral  acids — at  any  rate  in 
severe  cases  of  this  derangement — often  appear  to  be 
rather  injurious  than  beneficial ;  certainly  the  improve- 
ment under  their  use  is  not  nearly  so  rapid  as  in  cases 
where  alkalies  are  used.  The  influence  of  the  latter  in 
improving  the  appetite,  when  that  is  failing,  is  most 
marked,  especially  if  a  drop  or  two  of  dilute  hydrocyanic 
acid  be  added  to  each  dose  of  the  mixture,  and  will  often 
succeed  when  dilute  nitric  acid  has  beeii  given  without 
any  effect. 

Aloes  is  also  a  most  valuable  medicine.  Under  its  use 
the  amount  of  mucus  appearing  in  the  stools  diminishes 


TREATMENT 


223 


rapidly ;  the  digestion  improves  ;  and  all  the  symptoms 
showing  irritability  of  the  nervous  system — such  as  rest- 
lessness at  night,  bad  dreams,  startings,  grinding  of  the 
teeth,  moroseness,  and  ill  temper — quickly  subside.  The 
effect  upon  the  rest  at  night  is  usually  most  marked,  the 
child  beginning  to  sleep  soundly  after  only  a  few  doses  of 
the  drug.  The  most  convenient  form  in  which  it  can  be 
given  is  the  compound  decoction,  which,  if  well  made,  is 
seldom  objected  to  by  children ;  the  liquorice  and  the 
compound  tincture  of  cardamoms  it  contains  very  effec- 
tually disguising  the  nauseous  bitter  of  the  aloes.  It  may 
be  given  in  doses  of  one  or  two  drachms  twice  or  three 
times  in  the  day.  In  such  quantities,  especially  if  taken 
between  the  meals,  it  does  not  act  as  a  purgative,  but 
merely  produces  a  tonic  effect  upon  the  bowels,  checking 
immoderate  secretion. 

It  must  be  stated,  however,  that  the  aloes  appears  to 
be  more  beneficial  in  winter  than  in  summer.  In  warm 
weather  it  is  apt  to  be  too  irritating,  exciting  looseness  of 
the  bowels.  When  such  is  the  case  the  drug  should  be 
at  once  stopped,  and  a  change  be  made  to  alkalies,  or  to 
some  of  the  other  preparations  recommended. 

Decoction  of  oak  bark  in  half- ounce  doses  is  also  often 
of  service. 

In  cases  where  the  emaciation  and  debility  are  very 
decided,  iron  may  be  combined  with  the  special  treatment ; 
for  although  tonics,  when  given  alone,  are  found  to  be  of 
slight  advantage  so  long  as  the  functional  derangement  of 
the  alimentary  canal  continues  marked,  yet,  in  combination 
with  remedies  directed  especially  to  rectify  that  derange- 
ment, iron  is  often  of  much  use.  Thus  the  citrate  of  iron 
and  ammonia  may  be  given  with  sal  volatile  in  the  alkaline 
mixture,  or  a  teaspoonful  of  iron  wine  may  be  added  to 
each  dose  of  the  decoction  of  aloes,  or  the  aloes  may  be 
combined  with  the  tartrate  of  iron  and  potash,  as  in  the 
following  mixture : 


224 


MUCOUS  DISEASE 


]^    Ferri  Tartarati,  gr.  v, 
Decocti  Aloes  co., 
Aq.  ad  §ss.    M.    Ft.  haustus. 
To  be  taken  three  times  a  day  one  hour  after  food. 

During  the  course  of  the  above  treatment  it  will  be 
necessary*  to  prevent  the  accumulation  of  mucus  in  the 
bowels  by  the  occasional  administration  of  an  aperient. 
A  tea  spoonful  of  the  compound  liquorice  powder  may  be 
given  fasting,  twice  a  week ;  or  forty  to  sixty  drops  of  the 
liquid  extract  of  Rhamnus  frangula  may  be  given  in  a 
wineglassful  of  water. 

If,  as  is  so  often  the  case,  worms  be  present,  special 
measures  for  their  expulsion  must  be  resorted  to,  as  will 
be  described  in  the  following  chapter. 

The  following  case  well  illustrates  the  rapid  improve- 
ment which  takes  place  when  the  above  treatment  is 
adopted. 

John  R — ,  aged  11  years.  Had  an  attack  of  scarlatina 
three  years  ago,  and  has  since  been  persistently  wasting. 

He  was  first  seen  on  February  25th.  "  A  very  pale,  thin 
boy,  subject  to  occasional  attacks  of  faintness,  without, 
however,  actually  losing  consciousness.  Face  has  a  care- 
worn look,  and  he  is  troubled  with  an  occasional  short 
hacking  cough.  Appetite  very  bad.  Tongue  thickly  furred 
and  slimy,  with  depressed  large  pink  papillae  covering  its 
dorsum  and  sides.  Bowels  confined,  acting  about  every 
other  day ;  stools  hard  and  dark,  the  faecal  matter  often 
covered  with  mucus.  Occasionally  thread  worms  are  seen 
in  the  motions.  Sleeps  very  badly,  and  often  seems  to  be 
*  light-headed '  at  night.  Is  not  subject  to  attacks  of 
purging.  Never  perspires ;  the  skin  all  over  the  body  is 
exceedingly  rough  and  harsh ;  chest  and  belly  covered 
with  coarse,  dry  epithelium,  which  can  be  rubbed  off  as  a 

^  This  drug",  which  is  a  variety  of  the  buckthorn,  but  less  drastic  in 
operation  tlian  the  ordinary  Rhamnus  cathartica,  is  a  very  safe  and 
agreeable  aperient  for  cbildren. 


ILLUSTRATIVE  CASE 


225 


fine  dust.  Examination  of  the  lungs  and  heart  shows  no 
sign  of  disease." 

The  mother  was  directed  to  wash  the  boy  at  bedtime 
with  soap  and  hot  water  containing  soda,  and  afterwards 
to  anoint  his  whole  body  well  with  warm  olive  oil.  She 
was  to  repeat  the  oiling  every  night  after  bathing  him 
with  hot  water.  She  was  further  ordered  to  give  him  a 
tepid  sponge  bath  every  morning. 

Diet  to  consist  of  meat,  eggs,  and  milk,  with  a  little 
dry  stale  bread. 

The  following  medicines  were  prescribed  : — 

p,   Pulv.  Rhjei, 

Pulv.  Jalapse,  aa  gr.  vij, 

Pulv.  Scammon.,  gr.  x.    Ft.  pulv.  iv. 

One  powder  to  be  taken  every  other  morning. 

P>    Deeocti  Aloes  co., 

Vini  Ferri,  aa  5ij.    M.    Ft.  haustus. 
To  be  taken  three  times  a  day,  directly  after  food. 

The  improvement  in  this  case  was  most  rapid.  In  a 
week's  time  the  skin  had  become  naturally  soft  and  supple, 
and  the  boy  was  beginning  to  gain  flesh.  His  appetite 
improved,  and  he  slept  better  at  night.  The  increase  in 
weight  was  very  remarkable.  He  weighed  on  March  3rd, 
fifty-seven  pounds  ;  on  March  6th,  fifty-eight  pounds  ;  and 
on  March  15th,  sixty-two  pounds.  By  this  date  (March 
15th)  the  boy's  appearance  was  quite  changed;  he  had 
completely  lost  the  care-worn  look  which  had  been  so 
noticeable  on  his  face  at  the  first  visit,  and  the  cheeks 
were  much  fatter,  although  still  pale.  The  body  generally 
was  much  fatter,  and  presented  a  marked  contrast  to 
his  former  emaciation.  The  cough  was  gone;  he  slept 
soundly  at  night,  perspiring  a  little,  especially  about  the 
nose  and  mouth.  The  bowels  remained  costive,  and  the 
motions  hard,  but  they  contained  very  much  less  mucus, 
although  there  were  still  a  few  thread- worms  in  the  stools 
after  each  powder,  and  occasional  pains  in  the  belly  were 

15 


226 


MUCOUS  DISEASE 


still  complained  of.  The  tongue  was  much  pinker,  and 
had  lost  in  a  great  measure  its  slimy  appearance. 

We  sometimes  find  that  after  the  treatment  has  been 
continued  for  a  certain  time,  the  improvement  becomes 
less  rapid  or  even  ceases.  When  this  occurs  it  is  advisable 
to  change  from  alkaline  to  acid  medicines.  The  necessity 
for  the  change  seldom,  however,  occurs  before  the  tongue 
has  in  a  great  measure  lost  its  slimy  appearance,  and 
mucus  has  almost  ceased  to  be  seen  in  the  stools. 

In  such  cases  it  is  best  to  begin  with  a  nitro-muriatic 
mixture  with  a  bitter.    Thus  : — 

^    Acidi  Nitro-muriatici  dil.,  miij, 
Tinct.  Aurantii,  inx, 

Aq.  Chloroform i  ad  ^ss.    M.    Ft.  haustus. 

To  be  taken  before  food,  three  times  a  day. 

Other  acid  preparations  may  also  be  used,  as  the  Liquor 
Ferri  Pernitratis  in  bitter  infusion ;  quinine  with  dilute 
nitric  acid,  &c. 

Cod-liver  oil  is  of  comparatively  little  value  as  long  as 
the  mucous  flux  persists.  When,  however,  free  secretion 
from  the  mucous  membrane  has  been  controlled,  oil  will 
aid  in  repairing  the  effects  of  malnutrition  ;  but  it  should 
be  given  only  in  moderate  doses  (20  to  30  drops). 

Change  of  air  is  of  much  service.  Removal  to  a  bracing 
seaside  air,  such  as  that  of  Brighton  or  Westgate,  will 
often  after  a  very  short  stay  produce  a  very  great  im- 
provement in  the  symptoms  and  general  appearance  of 
the  child. 


CHAPTER  VII 


WORMS 

I^HE  varieties  of   parasitic  worms  found  in  children 
are : — 

Nematodes — 

Oxyuris  vermicularis,  the  small  thread- worm. 
Ascaris  lumhricoides,  the  long  round- worm. 
Tricocephalus  disjjar,  the  long  thread-worm. 

Cestodes  — 

Taenia  solium,  the  common  tape-worm. 

Taenia  medio -canellata,  the  hooldess  tape- worm. 

Bothriocephalus  lahts,  the  broad  tape- worm. 

Of  these  the  two  first- mentioned  varieties  are  by  far  the 
most  common  species  found  in  the  child.  The  taenia  is 
rare  in  children  under  the  age  of  six  years,  and  the  both- 
riocephalus  is  seldom  seen  in  England,  although  common 
enough  in  Switzerland  and  Russia.  When  found  in  this 
country,  it  is  usually  in  persons  who  have  resided  abroad. 

Description.^ — The  Oxyuris,  or  Ascaris  vermicularis, 
belongs  to  the  order  Nematoda.  The  male  measures  one- 
sixth  of  an  inch  in  length,  and  its  caudal  extremity  is 
obtusely  pointed.  The  female  is  from  a  third  to  half  an 
inch  in  length,  and  has  a  long,  gradually  tapering  capillary 
tail,  which  terminates  in  a  three-pointed  end.  This  has 
been  supposed  to  act  as  a  kind  of  holdfast. 

^  The  description  of  these  worms  is  borrowed  from  Dr.  Cobbold's 
work  on  Entozoa,  London,  1864. 


228 


WORMS 


Both  sexes  have  a  more  or  less  fusiform  body,  the 
anterior  end  being  narrowed  to  form  a  somewhat  abruptly 
truncated  head.  The  mouth  is  tripapillated,  leading  into 
a  triangular  oesophagus.  The  integument  is  transversely 
striated,  and  is  of  a  silvery  white  colour.  The  penis  is 
single,  simple,  and  very  minute.  The  eggs  are  long,  un- 
symmetrical,  and  measure  about  y  4V0  i^^-  f  I'om  pole  to  pole, 
and  -9^0  in.  the  greatest  transverse  diameter. 

The  seat  of  the  worms  is  the  caecum,  but  they  readily 
migrate  thence  into  the  sigmoid  flexure  and  rectum.  They 
are  not  found  in  infants  at  the  breast,  unless  other  food  is 
being  given  at  the  same  time  with  the  breast-milk,  but  are 
exceedingly  common  in  older  children. 

The  Ascaris  lumhricoides,  also  a  nematode,  is  much 
larger  than  the  preceding.  The  male  measures  from  four 
to  six  inches  long,  the  female  from  ten  to  fourteen.  The 
body,  smooth,  fusiform,  and  elastic,  is  marked  by  fine 
transverse  rings,  and  tapers  gradually  towards  either 
extremity.  The  mouth  is  tripapillated  ;  the  tail  is  obtusely 
pointed.  The  male  is  distinguished  from  the  female  by  a 
double  penis,  and  by  the  arcuate  form  of  its  tail.  The 
female  is  broader  than  the  male,  being  about  a  quarter  of 
an  inch  in  diameter. 

These  worms  inhabit  principally  the  small  intestine,  but 
often  pass  into  the  stomach  and  other  parts  of  the  ali- 
mentary canal.  They  are  most  common  between  the  ages 
of  three  and  ten  years.  Their  number  varies  from  two  or 
three  to  twenty,  thirty,  or  even  more  ;  they  are  seldom 
solitary. 

The  Tricocep/ialus  dispar  is  not  very  common  in  England, 
but  is  sometimes  found  after  convalescence  from  typhoid 
fever.  The  male  measures  an  inch  and  a  half  in  length, 
the  female  two  inches.  This  worm  is  specially  character- 
ised by  an  extremely  long  filiform  neck,  which  occupies 
about  two-thirds  of  the  length  of  the  body.  The  surface 
of  the  skin  is  smooth  to  the  naked  eye,  but  when  magni- 


TAENIA  SOLIUM 


229 


fied  is  found  to  have  on  one  side  a  longitudinal  band  of 
minute  wart- like  papillae,  at  the  borders  of  which  the 
ordinary  circular  striae  of  the  integument  terminate. 
The  tail  of  the  male  worm  is  curved,  and  has  at  the  ex- 
tremity a  short  tubular  penis -sheath  armed  with  minute 
retroverted  spines.  The  tail  of  the  female  is  straight  and 
blunt-pointed. 

The  worm  inhabits  chiefly  the  caecum  and  the  colon. 

The  Tdenia  solium  belongs  to  the  order  Gestoda.  Its 
length  is  very  great,  often  ten,  twenty,  thirty  feet,  or  even 
more.  In  breadth  it  is  about  a  third  of  an  inch  at  its 
widest  part.  The  head,  globular  and  about  the  size  of 
the  head  of  a  small  pin,  is  produced  in  front  so  as  to  form 
a  short  cylindrical  proboscis,  which  is  armed  with  a 
double  crown  of  hooks  numbering  from  twenty-two  to 
twenty-eight  in  each  circular  row.  The  head  is  also 
furnished  with  four  sucking  discs,  situated  at  the  four 
angles.  The  neck  is  very  narrow,  and  is  about  half  an 
inch  in  length  ;  it  is  continued  into  the  anterior  part  of 
the  body,  which  is  sexually  immature,  and  presents  only 
traces  of  segmentation  in  the  form  of  fine  transverse  lines. 
These  lines  become  gradually  more  and  more  widely 
separated,  having  short  interspaces ;  and  eventually  the 
imperfect  segments  become  more  distinctly  marked,  and 
true  joints  are  seen.  The  earliest  formed  immature  joints 
are  very  narrow ;  and  it  is  not  until  about  the  four 
hundred  and  fiftieth  segment  from  the  head  that  they 
become  sexually  mature.  The  mature  segment  is  called 
pro- glottis."  The  total  number  of  joints,  in  a  worm 
ten  feet  long,  is  about  eight  hundred.  A  mature  pro- 
glottis is  about  twice  as  long  as  it  is  broad.  It  is  com- 
paratively thin  and  transparent,  and  is  furnished  with  a 
branched  uterus,  which  consists  of  a  central,  longitudinal 
stem,  giving  off  from  seven  to  ten  branches  on  either  side. 
Each  joint  has  a  common  reproductive  papilla  placed  at 
the  border  on  one  side  below  the  middle  line,  but  not 


230 


WORMS 


nniformly  to  the  right  or  left  in  series.  The  male  orifice 
is  above  the  vaginal  outlet.  The  penis  is  sickle- shaped. 
The  Taenia  solium  is  usually  solitary.  It  is  seldom  seen 
in  children  under  three  years  old.  Its  seat  is  the  small 
intestine. 

The  Tdenia  medio -canellata  resembles  the  preceding  in 
every  respect  except  in  the  head;  the  cylindrical  pro- 
boscis and  the  double  crown  of  hooks  being  absent. 

The  Botliriocejphalus  latus  is  the  largest  of  the  Xiestode 
worms  which  infest  the  human  body.  In  length,  it  is 
often  five- and- twenty  feet,  and  it  is  about  an  inch  in 
breadth. 

The  head  measures  one-twenty-fifth  of  an  inch  in 
breadth,  is  blunt  at  the  top,  elongated,  and  slightly  flat- 
tened from  behind  forwards.  It  is  furnished  with  two 
laterally  disposed  slit-like  grooves,  but  is  destitute  of 
hooks.  The  anterior  segments,  which  are  sexually  imma- 
ture, are  extremely  narrow,  and  enlarge  very  gradually 
from  above  downwards.  After  reaching  their  greatest 
width  in  the  centre  of  the  body,  they  begin  gradually  to 
decrease  in  width,  but  increase  in  depth  ;  so  that  while  in 
the  central  segments  the  width  is  much  greater  than  the 
depth,  being  as  one  inch  to  one-eighth  of  an  inch,  in  the 
joints  near  the  caudal  extremity  the  breadth  and  the 
depth  are  about  equal,  being  frequently  a  quarter  of  an 
inch  in  either  measurement.  The  body  is  flattened,  but 
not  so  uniformly  as  is  found  in  the  Taenia  solium,  as  it 
is  rather  thicker  in  the  centre  than  at  the  sides.  The 
total  number  of  joints  has  been  estimated  at  about  four 
thousand,  the  first  sexually  mature  one  being  the  six- 
hundredth  from  the  head. 

The  reproductive  orifices  are  in  the  middle  line  towards 
the  upper  part  of  the  segment  on  the  ventral  aspect. 
The  vaginal  aperture  is  immediately  below  the  male 
outlet,  and  both  openings  are  surrounded  by  papilliform 
eminences.    The  uterus  consists  of  a  single  tube,  often 


MODE   OF  ADMISSION 


231 


folded  regularly  upon  itself  so  as  to  form  an  opaque 
centrally- disposed  rosette-like  mass. 

The  embryo  is  ciliated,  and  moves  freely  about  in 
water. 

All  these  varieties  of  worm  obtain  admission  into  the 
human  body  by  the  mouth.  The  ova  of  the  thread-worm 
are  introduced  adhering  to  fruit,  cresses,  and  other  articles 
of  food.  Sometimes,  also,  they  are  conveyed  to  the 
mouth  directly  by  the  child.  The  ova  of  the  oxyuris 
are  very  numerous,  and  when  exposed  to  the  action  of  the 
gastric  juice,  the  tadpole- shaped  embryos  escape  from  the 
eggs  into  the  stomach.  The  creatures  develop  rapidly  as 
they  pass  down  the  alimentary  canal,  and  have  reached 
maturity  by  the  time  the  caecum  is  arrived  at.  The 
eggs  deposited  at  this  part  of  the  digestive  tract  are  not 
hatched,  but  escape  in  large  numbers  by  the  bowels. 
Dr.  Cobbold  states  that  children  often  carry  the  ova  in 
large  numbers  under  their  nails ;  for  the  excessive  itching 
of  the  fundament,  to  which  the  presence  of  the  parasites 
gives  rise,  necessitates  much  rubbing  and  scratching  for 
its  relief.  By  this  means  a  continual  supply  of  ova  can  be 
introduced  into  the  mouth. 

From  observations  made  by  G-rassi,  it  seems  probable 
that  the  common  house  fly  may  sometimes  serve  as  the 
medium  by  which  the  eggs  of  parasitic  worms  are  con- 
veyed to  the  human  subject.  This  observer  has  shown 
by  direct  experiment  that  the  insects  are  able  to  take  in 
the  ova  of  certain  worms  by  the  mouth  and  void  them 
unchanged  in  the  faeces.  In  this  way  eggs  may  be  depo- 
sited directly  upon  the  food  shortly  before  the  child 
swallows  it. 

In  the  case  of  the  Ascaris  lumbricoides,  the  drinking 
of  impure,  unfiltered  water  is  the  ordinary  method  of 
admission.    M.  Davaine^  doubted  whether  the  embryos 

^  C.  Davaine,  "Recherches  sur  le  Developpement  et  la  Propagation 


232 


WORMS 


could  become  developed  in  the  liuman  intestine;  but 
Heller  states  that  the  eggs  may  be  hatched,  and  the 
embryos  escape,  and  develop  into  the  mature  worm,  while 
still  in  the  alimentary  canal  of  the  person  infested  with 
them.  Out  of  the  body  the  embryos  develop  very  slowly, 
for  Davaine  kept  some  alive  for  a  period  of  five  years 
without  the  embryos  making  any  attempt  to  escape  from 
their  shells.  The  creatures  have,  however,  a  singular 
tenacity  of  life,  for  they  cannot  be  destroyed  by  frost, 
and  even,  it  is  said,  survive  complete  desiccation. 

In  the  case  of  the  Taenia,  each  pro-glottis,  or  mature 
segment,  is  complete  in  itself,  being  furnished  with  male 
and  female  reproductive  organs.  When  this  has  become 
impregnated,  by  contact  with  another  pro-glottis,  eggs 
are  formed  in  it.  In  each  egg  is  developed  an  embryo 
which  remains  unhatched  as  long  as  the  ovum  continues 
in  the  body  of  the  parent.  The  segment,  after  its  expul- 
sion from  the  bowel,  moves  about  for  a  time  until  it 
bursts  from  the  growth  of  the  embryos  in  its  interior, 
and  the  ova  escape.  Each  embryo  is  provided  with  a 
boring  apparatus,  having  three  pairs  of  hooks  at  its 
anterior  end.  Unlike  the  other  worms  which  have  been 
described,  the  embryo  of  the  tape- worm  cannot  pass 
through  all  the  stages  of  its  development  in  the  body  of 
the  same  individual.  The  creature  does  not  develop 
directly  into  the  perfect  taenia,  but  passes  through  a  stage 
of  transition.  This  stage  requires  to  be  completed  in  the 
body  of  an  intermediary.  Thus,  when  eaten  by  some 
animal,  such  as  a  pig  or  a  rabbit,  the  embryo  breaks  its 
shell,  and,  boring  through  the  intestinal  wall  of  the 
animal,  lodges  itself  in  the  fatty  parts  of  the  flesh.  It 
then  drops  its  hooks  and  becomes  the  well-known  Cysti- 
cercus  cellulosse.  When  the  flesh  of  an  animal  containing 
the  Cysticercus  is  eaten,  the  parasite  attaches  itself  to  the 

du  Tricocephale  de  rHoinme  et  de  TAscaride  Lombricoide,"  '  Comptes 
rcndus  a  I'Academie  dcs  Sciences/  t.  xlvi,  21  Juiii,  1858. 


SYMPTOMS 


233 


wall  of  the  bowel,  and  growing  from  its  lower  or  caudal 
extremity,  develops  into  the  community  of  individually 
distinct  creatures  which  is  known  as  the  perfect  tape- 
worm. 

It  appears,  therefore,  that  flesh  infested  with  the  cysti- 
cercus  is  the  ordinary  source  from  which  the  taeniae  are 
derived.  Pigs  are  very  liable  to  be  so  infested,  and  in 
rabbits  it  is  exceedingly  common,  very  few  being  found 
altogether  free  from  tape-worm ;  in  these  animals  it  is 
the  Taenia  solium. 

Oxen  are  sometimes  infested  with  the  embryo  of  the 
Taenia  medio -canellata ;  and  in  children  treated  for  chronic 
diarrhoea  upon  the  raw  meat  plan,  and  who  become  in 
consequence  affected  with  tape- worm,  as  is  said  sometimes 
to  happen,  it  is  to  this  worm  that  their  symptoms  are  due. 
Indeed,  it  may  be  said  that  in  the  human  subject,  of  all 
the  varieties  of  tape- worm,  the  Taenia  medio -canellata  is 
the  one  most  frequently  met  with. 

The  transitional  stage  of  the  Bothriocephalus  latus, 
according  to  Dr.  Braun  of  Dorpat,  is  completed  in  the 
body  of  the  pike. 

Symptoms. —  The  presence  of  worms  in  children  is 
usually  accompanied  by  an  unhealthy  condition  of  the 
alimentary  canal,  which  precedes  their  appearance,  and 
continues  after  the  worms  have  been  expelled.  Perhaps 
few  of  the  symptoms — and  they  are  very  numerous — which 
are  found  while  the  worms  exist  in  the  body,  can  be  directly 
attributed  to  the  presence  of  these  parasites,  as  they  may 
all  of  them,  or  nearly  all,  be  found  also  in  cases  where 
repeated  purgatives  have  convinced  us  that  worms  are 
absent.  They  are,  therefore,  probably  due  in  great  part 
to  the  abdominal  derangement  which  favours  the  develop- 
ment of  the  entozoa. 

This  derangement  has  been  already  described  in  the  pre- 
vious chapter. 

As  a  result  of  it,  nutrition  becomes  impaired,  and  the 


234 


WORMS 


child  wastes.  The  face  becomes  pn%  and  pale ;  the  lower 
eyelids  dark,  and  sometimes  leaden-coloured ;  the  pupils 
often  dilated.  There  is  itching  of  the  nose  and  anus  ; 
epistaxis  may  occur ;  and  the  sense  of  smell  is  occasionally 
depraved  or  lost.  The  upper  lip  often  swells  ;  the  breath 
is  foetid,  especially  in  the  mornings ;  and  salivation  is 
sometimes  noticed,  the  saliva  running  from  the  mouth  on 
to  the  pillow  during  sleep. 

At  night  the  child  is  very  restless ;  during  sleep  he 
starts,  twitches,  and  grinds  his  teeth  ;  and  he  often  wakes 
in  great  panic,  crying  and  talking  wildly.  There  is  often 
a  frequent  dry  troublesome  cough,  a  symptom  considered 
by  Stoll  very  characteristic  of  the  presence  of  worms  ; 
and  sighing,  sobbing,  and  hiccough  are  not  uncommon. 

The  belly  is  swollen  and  hard.  Pain  in  the  abdomen  is 
often  complained  of,  the  pain  being  usually  confined  to 
one  or  two  points,  especially  about  the  umbilicus.  In 
character  it  is  tearing  or  cutting,  although  sometimes  it 
is  merely  an  uneasy  creeping  sensation,  or  a  feeling  of 
cold  in  the  bowels.  The  pain  is  sometimes  felt  in  the 
chest. 

The  appetite  is  capricious.  At  one  time  there  is  con- 
stant craving,  the  hunger  seeming  to  be  almost  insatiable  ; 
at  others  the  child  refuses  all  food,  and  great  anxiety  is 
excited  by  the  difficulty  found  in  persuading  him  to  take 
nourishment.  Sudden  attacks  of  nausea  may  come  on 
with  sour- smelling  eructations,  and  vomiting  may  occur 
with  expulsion  of  worms  from  the  mouth.  Lumbrici  are 
not  unfrequently  ejected  in  this  way.  The  bowels  are 
much  confined ;  the  constipation  yielding  readily  to  pur- 
gatives, but  returning  when  the  action  of  the  medicine 
has  subsided.  Sometimes  there  is  tenesmus,  with  con- 
stant ineffectual  desire  to  go  to  stool ;  and  attacks  of 
diarrhoea  are  very  liable  to  come  on,  with  very  great 
straining,  the  motions  passed  being  black,  slimy,  and 
extremely  offensive.    Micturition  is  often  painful  and 


SYMPTOMS 


285 


difficult,  and  the  urine  whitish  or  milky.  Discharges  of 
mucus  may  take  place  from  the  rectum,  and  in  female 
children  often  from  the  vagina. 

The  pulse  is  often  small,  quick  or  slow,  and  irregular. 
The  temper  is  irritable,  or  the  child  is  sullen  and  morose. 
Attacks  of  syncope  are  sometimes  seen,  and  there  may 
be  passing  delirium,  or  even  profound  stupor.  Other  dis- 
ordered conditions  are  enumerated  as  resulting  from  the 
presence  of  worms,  as  sudden  blindness,  loss  of  voice, 
squinting,  or  fixed  state  of  the  eyes,  vertigo,  general  con- 
vulsions. According  to  Dr.  Underwood,  an  attack  of 
convulsions,  accompanied  by  small  pulse  and  hiccough,  is 
an  almost  certain  sign  of  worms. 

As  the  majority  of  these  symptoms  are  due,  not  to  the 
worms,  but  to  the  condition  of  the  alimentary  canal 
usually  accompanying  the  parasites,  the  symptoms  are 
severe  in  proportion  to  the  abundance  of  the  mucous  flux. 
If  this  be  copious,  digestion  is  very  greatly  interfered 
with,  nutrition  is  seriously  impaired,  and  all  the  sym- 
ptoms arising  from  indigestion  and  irritability  of  the 
nervous  system  are  strongly  marked.  Worms  may,  how- 
ever, be  found  in  children  in  whom  the  alimentary  canal 
is  almost  healthy.  The  general  symptoms  are  in  such 
cases  exceeding  trifling,  and  the  appearance  of  the  tongue 
differs  widely  from  that  described  in  mucous  disease. It 
is  then  neither  flabby  nor  slimy ;  but  is  small  and  pointed, 
reddish  at  the  tip,  and  is  covered  on  the  dorsum  with  a 
thin  curdy  fur.  The  papillae  are  still  large,  but  are  less 
conspicuous,  and  their  outline,  instead  of  being  evenly  and 
clearly  marked,  is  very  irregular. 

Certain  special  symptoms  are  associated  with  different 
varieties  of  worm. 

The  Oxyuris  vermicularis  occasions  violent  itching  at 
the  anus.  This  is  most  marked  towards  the  evening ; 
and  the  irritation  not  only  prevents  the  child  from  going 
*  See  page  211. 


236 


WOE-MS 


to  sleep,  but  may  be  so  intense  as  to  produce  extreme 
distress.  The  irritation,  propagated  to  neighbouring  parts, 
may  excite  a  mucous  discharge  from  the  vagina,  and  is 
sometimes  a  cause  of  masturbation. 

A  common  symptom  where  these  small  thread-worms 
are  present  is  tenesmus,  the  desire  to  go  to  stool  being 
frequent  but  ineffectual ;  and  the  straining  may  cause 
prolapsus  ani,  which  often  continues  after  the  worms  have 
been  expelled.  Besides,  the  irritation  propagated  over  the 
whole  intestinal  tract  is  apt  to  give  rise  to  diarrhoea. 
Migration  of  the  Oxyuris  occasionally  takes  place,  and 
cases  are  on  record  in  which  these  worms  were  found  in 
the  vagina,  uterus,  urethra,  oesophagus,  and  stomach. 

When  the  presence  of  the  Oxyures  is  suspected,  they 
will  be  often  found  on  examination  moving  about  in  the 
radiating  folds  around  the  anus. 

The  Ascaris  lumhricoides  gives  rise  to  pain  more  or  less 
severe,  situated  at  one  or  two  points  of  the  belly  in  the 
neighbourhood  of  the  umbilicus.  Sudden  nausea  is  apt 
to  occur  from  the  passage  of  the  worm  into  the  stomach, 
and  it  is  sometimes  expelled  by  the  mouth.  The  lumbri- 
cus  is  more  apt  than  the  preceding  variety  to  give  rise  to 
nervous  symptoms ;  and  vertigo,  convulsions,  chorea,  &c., 
sometimes  seem  to  result  from  its  presence.  These  sym- 
ptoms are  usually  ascribed  to  reflex  irritation,  but  recent 
observations  suggest  that  they  are,  sometimes  at  any  rate, 
toxic  in  character  from  a  poisonous  substance  contained  in 
the  parasites  or  secreted  by  them. 

The  irritation  of  the  lumbrici  may  give  rise  to  a  chronic 
diarrhoea,  lasting  often  for  months.  The  motions  are 
scanty,  offensive,  of  the  colour  and  consistence  of  thin 
mud,  and  are  evacuated  with  much  straining  and  some- 
times prolapsus  ani.  They  are  more  frequent  in  the  night 
than  during  the  day.  A  child  of  three  years  old  lately 
came  under  the  writer's  notice,  who  had  suffered  for 
nearly  eight   months  from   persistent  looseness  of  the 


SYMPTOMS  OF  LONG  ROUND-WORM  237 

bowels.  The  diarrhoea  ceased  after  the  expulsion  of  twelve 
lumbrici. 

The  luinbricus  is  very  migratory  in  its  habits.  The 
wanderings  of  these  worms  usually  occur  at  night.  At 
this  time  they  become  very  active,  and  may  pass  out  of 
the  alimentary  canal  into  passages  communicating  with 
it,  or  even  into  adjacent  organs  which  have  no  direct 
communication  with  the  digestive  tube.  Thus,  they  have 
been  noticed  in  the  common  bile-duct,  and  in  the  gall- 
bladder, in  two  cases  recorded  by  M.  Gruersant,  where 
the  children  died  suddenly  in  violent  convulsions.  They 
have  also  been  seen  in  the  nasal  passages,  the  larynx, 
trachea,  the  larger  bronchi,  in  the  vagina,  and  even  in  the 
urethra  and  bladder.  Again,  the  worms  may  be  found  in 
abscesses  communicating  with  the  intestine,  having  escaped 
from  the  bowel  by  entering  a  pre-existing  fistulous  opening. 
The  abscesses  are  generally  in  some  part  of  the  abdominal 
wall,  usually  the  umbilical  or  inguinal  regions,  or  in  the 
substance  of  the  liver. 

The  passage  of  a  lumbricus  into  the  windpipe  is  a 
rare  but  very  dangerous  accident.  This  mishap  has 
occurred  more  frequently  than  might  be  anticipated,  for 
nine  cases  have  been  collected  by  Dr.  Fiirst,  of  Vienna, 
and  no  less  than  sixteen  have  been  recorded  by  Davaine. 
If  the  worm  remain  in  the  glottis,  its  presence  gives  rise 
to  the  most  intense  dyspnoea  and  complete  loss  of  voice ; 
and  the  patient  very  shortly  dies  asphyxiated.  If  the 
parasite  pass  into  the  trachea  or  bronchus,  there  is 
dyspnoea  occurring  in  violent  paroxysms,  and  pain  re- 
ferred to  the  front  of  the  chest.  Aphonia  may  persist 
or  the  voice  may  partially  return.  The  irritation  induced 
by  the  presence  of  the  worm  soon  sets  up  bronchitis,  and 
the  child,  if  not  carried  off  early  by  suffocation,  usually 
succumbs  more  or  less  quickly  to  this  complication.  In 
such  cases  as  these  it  is  by  no  means  easy  to  discover  the 
cause  of  the  sudden  interference  with  respiration ;  for  the 


238 


WORMS 


only  clue  to  the  presence  of  a  lumbricas  would  be  the 
knowledge  that  the  patient  had  previously  suffered  from 
these  worms.  If  the  access  take  place  first  at  night-time, 
the  symptoms  would  be  probably  referred  to  an  attack  of 
stridulons  laryngitis.  If  in  the  day,  the  fact  of  the 
patient's  freedom  from  catarrh,  or  any  tendency  to  hoarse- 
ness, would  perhaps  suggest  the  presence  of  a  foreign 
body  in  the  windpipe,  but  the  nature  of  the  intruding 
substance  could  hardly  be  divined  in  the  absence  of  special 
information. 

The  Tdenidd  produce  sensations  of  weight,  and  sometimes 
of  gnawing  in  the  belly,  rising  occasionally  to  severe 
attacks  of  colic,  accompanied  by  considerable  swelling  of 
the  abdomen,  especially  about  the  umbilicus.  The  appe- 
tite is  usually  large,  and  there  is  progressive  emaciation, 
which  is  more  marked  than  in  the  other  varieties.  Vomit- 
ing and  diarrhoea  are  rare.  Cephalalgia  is  not  common, 
but  when  it  occurs  it  is  often  remarkably  persistent. 
There  is  usually  great  lassitude,  with  sometimes  cramps 
in  the  extremities.  Fragments  of  the  worm  are  passed  in 
the  stools. 

With  the  presence  of  the  Tricoceplialus  dispar  no  special 
symptoms  have  been  associated. 

Diagnosis. — The  only  satisfactory  proof  of  worms  is 
their  presence  in  the  stools ;  any  symptom  or  any  combi- 
nation of  symptoms  may  be  produced  by  other  diseases, 
so  that  a  purgative  becomes  the  crucial  test.  It  must  be 
remembered,  however,  that  although  worms  may  be  pre- 
sent, it  does  not  necessarily  follow  that  they  have  been 
the  cause  of  the  symptoms  for  which  advice  is  required. 
Tuberculosis,  rickets,  or  other  constitutional  diseases  may 
exist  at  the  same  time,  the  presence  of  the  entozoa  being 
an  accidental  and  often  a  trifling  complication.  In  such 
cases  the  symptoms  will  continue  after  the  worms  have 
been  expelled. 

The  fact  appears  to  be  that  the  large  majority  of  the 


DIAGNOSIS 


239 


symptoms  are  due  to  the  derangement  of  the  stomach  and 
bowels  which  is  almost  always  associated  with  the  para- 
sites, and  of  which  they  appear  to  be  rather  a  result  than 
a  cause,  although  no  doubt  the  irritation  they  excite  tends 
to  encourage  the  derangement.  When  the  mucous  mem- 
brane of  the  alimentary  canal  is  in  a  healthy  state  there  is 
no  nidus  for  worms,  and  it  appears  probable  that  a  favour- 
able medium  is  essential  to  their  development  in  any 
quantity.  The  required  nidus  is  found  in  the  alkaline 
mucus  which  is  so  abundantly  secreted ;  and  in  this  they 
develop  very  rapidly.  It  is  more  important  to  detect  the 
presence  of  some  worms  than  of  others.  The  taeniae  pro- 
duce very  great  emaciation  ;  and  the  lumbrici,  if  present  in 
large  numbers,  may  cause  serious  interference  with  nutri- 
tion ;  but  the  oxyures  are  of  comparatively  little  moment, 
and  unless  the  irritation  be  so  great  as  to  prevent  sleep, 
are  seldom  attended  with  any  great  inconvenience. 

The  symptoms  attending  the  presence  of  worms  may  be 
so  severe  as  to  give  rise  to  suspicion  of  the  formation  of 
tubercle.  Thus,  if  a  child  has  irregular  attacks  of  fever ; 
begins  to  lose  flesh ;  sleeps  badly,  grinding  his  teeth  at 
night ;  becomes  pale  and  heavy-eyed ;  loses  his  cheerful- 
ness, and  gets  languid  and  dull ;  has  a  capricious  appetite, 
being  sometimes  ravenous,  and  at  other  times  showing  a 
disgust  for  food,  with  bowels  alternately  relaxed  and  con- 
stipated— in  such  a  case  the  existence  of  tuberculosis  may 
be  suspected.  If,  however,  the  symptoms  are  due  to 
worms,  an  active  purgative  will  give  evidence  of  their 
presence,  and  by  clearing  away  a  quantity  of  the  tenacious 
mucus  will  cause  an  immediate  improvement  in  the  symp- 
toms ;  afterwards  suitable  remedies  and  careful  diet  will 
restore  the  alimentary  canal  to  a  healthy  condition  (see 
Diagnosis  of  Mucous  Disease,  p.  218). 

In  other  cases,  where  the  nervous  symptoms  are  well 
marked,  and  are  accompanied  by  a  dilatation  of  the  pupils, 
vomiting  of  watery  fluid,  constipation,  and  a  slow,  irregular 


240 


WORMS 


pulse,  tubercular  meningitis  may  be  suspected.  Here, 
however,  the  fact  that  signs  of  digestive  derangement  have 
preceded  the  nervous  symptoms,  the  absence  of  headache 
and  of  fever,  the  readiness  with  which  the  constipation 
yields  to  a  mild  purgative,  and  the  relief  to  the  symptoms 
which  follows  the  action  of  the  aperient,  will  clear  up  the 
diagnosis.  Besides,  in  these  cases  a  history  can  often  be 
obtained  of  the  previous  occurrence  of  similar  attacks. 

In  cases  where  abdominal  pains  are  complained  of  by 
children  a  careful  examination  of  the  chest  should  always 
be  made,  as  in  them  the  pain  of  pleurisy  is  very  commonly 
referred  to  the  belly,  and  not  to  the  thorax. 

Treatment.^ — In  the  treatment  of  worms,  it  is  not  suffi- 
cient to  expel  the  parasites  from  the  body,  for  so  long  as 
the  unhealthy  condition  of  the  alimentary  canal  continues 
to  provide  a  nidus  for  the  entozoa,  they  may  be  reproduced 
again  and  again  as  often  as  they  are  driven  out.  There 
are,  therefore,  two  indications  to  fulfil  in  the  treatment  o£ 
this  complaint,  viz. : — 

To  expel  the  worms. 

To  destroy  the  nidus  by  restoring  the  alimentary  canal 
to  a  healthy  condition. 

To  expel  the  worms  different  measures  must  be  employed, 
according  to  the  variety  of  worm  to  be  attacked. 

The  oxyureSy  which  inhabit  the  caecum  and  lower  bowel, 
are  within  the  reach  of  injections,  and  are  best  treated  by 
this  means.  Various  enemata  may  be  used ;  thus,  four  or 
five  ounces  of  strong  infusion  of  quassia,  to  which  twenty 
drops  of  Tinct.  Ferri  Perchloridi  have  been  added ;  the 
same  quantity  of  lime-water ;  or  a  solution  of  one  drachm 
of  common  salt,  dissolved  in  five  ounces  of  distilled  water, 
may  be  administered.  Whatever  form  of  enema  be  used, 
it  should  be  given  at  bedtime,  should  be  used  tepid,  and 
should  be  preceded  by  a  large  injection  (30  oz.)  of  warm 

^  All  the  prescriptions  given  in  this  chapter  are  adapted  to  a  child 
of  four  years  old. 


\ 


TREATMENT  241 

soap  and  water,  so  as  to  empty  the  colon  as  thoroughly  as 
possible. 

If  these  measures  do  not  prove  successful  in  removing 
the  parasites,  santonine  may  be  given  in  conjunction  with 
naphthalin  and  an  aperient  on  several  successive  evenings, 
as  in  the  following  powder  : — 

]^    Santonini,  gr.  j, 
Naphthalin,  gr.  ij, 
Jalapin,  gr.  ij.    M.    Ft.  pulv. 
Sig.    To  be  taken  at  bedtime. 

The  diarrhoea,  which  is  so  common  when  the  oxyures 
are  present,  is  readily  arrested  by  a  purgative,  as  castor 
oil,  or  the  following  powder  :  — 

p,    Pulv.  Rhjei,  gr.  viij, 

Pulv.  Cretse  Aromat.,  gr.  ij, 
Hyd.  cum  Creta,  gr.  ij.    Ft.  pulv. 

Primo  mane  sumendus. 

This  powder  should  be  given  every  second  or  third 
morning,  and  every  evening  the  injection  should  be  re- 
peated, until  no  trace  of  the  worms  is  found  in  the  stools 
or  in  the  returning  enema. 

G-reat  irritation  of  the  rectum  may  be  allayed  by  the 
injection  of  an  ounce  of  thin  warm  starch,  containing,  if 
necessary,  a  few  drops  of  laudanum,  before  the  child  is 
put  to  bed;  or  a  towel  wetted  with  cold  water  may  be 
applied  to  the  fundament  while  in  bed. 

For  the  lumhriciis  and  the  Tricocephalns  disjpar  the  best 
remedy  is  santonine,  which  may  be  given  either  alone  or 
combined  with  purgatives.  A  good  combination  is  the 
following :  — 

Santonini,  gr.  viij, 

Pulv.  Zingib.,  gr.  x, 

Pulv.  Jalapse,  5ss, 

Sulphuris  Loti,  5iss, 

Couf.  Seunse,  ^j.    M.    Ft.  confectio. 

16 


242 


WORMS 


Of  this  confection  a  teaspoonful  should  be  given  every 
morning.  Or  santonine  may  be  usefully  combined  with 
calomel,  as  in  the  following  powder : — 

Suntoniui,  gr.  j, 

Hydrargyri  Subchlorid.,  gr.  j.    Ft.  pulv.    Mitte  iij. 
Sig.    One  powder  to  be  given  every  night.    To  be  followed 
each  morning  by  half  an  ounce  of  castor  oil. 

When  given  alone,  santonine  is  conveniently  administered 
sprinkled  on  a  slice  of  bread  and  honey,  in  doses  of  one  or 
two  grains,  twice  or  thrice  in  the  day.  In  such  cases  an 
occasional  aperient  will  be  required  to  carry  off  the  dead 
worms. 

Santonine  usually  increases  the  flow  of  urine,  and  may 
give  a  reddish  tint  to  that  secretion.  Another  effect 
sometimes  found  to  be  produced  by  the  drug  is  a  peculiar 
perversion  of  the  sight,  in  which  all  objects  are  seen  of  a 
green  colour.  This  symptom  is  of  no  importance,  and 
readily  passes  away  when  the  drug  is  omitted,  but  it  is 
well  to  warn  parents  of  its  liability  to  occur.  It  is,  how- 
ever, necessary  to  know  that  some  children  are  unusually 
susceptible  to  the  action  of  santonine.  A  dose  as  small 
as  four  grains  has  been  known,  in  a  child  of  four  years 
old,  to  i^roduce  profound  coma  a,nd  stertorous  breathing, 
with  depression  which  has  lasted  more  or  less  for  twenty- 
four  hours.  The  drug  is  not  very  rapidly  taken  up  by 
the  absorbent  vessels.  Therefore  in  all  cases  where 
poisonous  symptoms  are  noted  a  stiff  aperient  should  be 
administered  without  delay  to  remove  any  unabsorbed 
portion  of  the  drug  from  the  bowels.  At  the  same  time 
the  child  should  be  plied  with  diuretics  to  hasten  the 
elimination  by  the  kidneys  of  the  poison  already  absorbed 
into  the  circulation. 

Many  other  drugs  have  been  recommended  for  the  ex- 
pulsion of  these  worms ;  thus  mercury,  antimony,  granu- 
lated tin,  nitrate  of  silver,  and  arsenic;  kamala,  kousso, 
assafoetida,  tannin,  valerian,  and  Corsican  moss ;  all  these 


TREATMENT 


243 


drugs  alone,  or  variously  combined,  have  been  used  and 
found  successful  in  these  cases.  Cov^hage  (the  hairs  of 
the  Mucuna  jpruriens),  in  doses  of  thirty  to  sixty  grains 
given  twice  a  day  in  syrup  or  treacle,  is  a  favourite  remedy 
with  some.  The  sulphites,  especially  the  bisulphite  of 
soda  (ten  grains  three  times  a  day  with  Tinct.  Aiirantii),  are 
stated  by  Dr.  W.  E»oe  to  have  a  powerful  anthelmintic 
action,  possibly,  as  he  suggests,  from  the  sulphurous  acid 
set  free  by  contact  with  acid  secretions.  The  medicine  has 
no  cathartic  action,  and  therefore  an  aperient  is  required 
in  most  cases  to  remove  the  worms  killed  by  the  remedy. 
In  all  cases,  if  the  drug  employed  be  not  in  itself  purga- 
tive, it  is  well  to  combine  it  with  some  aperient,  or  at  any 
rate  to  act  gently  upon  the  bowels,  from  time  to  time,  so 
long  as  the  remedy  is  in  use.  Violent  purgatives  are  not 
needed,  the  repeated  action  of  mild  aperients  being  equally 
efficient  in  causing  expulsion  of  the  worms,  without  ex- 
citing so  much  irritation  of  the  digestive  canal. 

In  cases  where  a  sudden  attack  of  dyspnoea  with  aphonia 
occurs  in  a  child  known  to  be  suffering  from  a  lumbricus, 
the  absence  of  symptoms  pointing  to  another  cause  for 
the  patient's  distress  might  lead  us  to  suspect  the  intru- 
sion of  a  worm  into  the  windpipe.  If  we  feel  satisfied  as 
to  the  correctness  of  the  diagnosis,  tracheotomy  should 
be  performed  without  delay.  The  worm  can  then  be 
extracted  with  the  forceps. 

So  long  as  we  have  to  deal  with  worms  such  as  the 
preceding,  expulsion  is  easily  effected,  but  a  case  of  taiiiia 
presents  more  difficulty.  Tapeworms  are  often  exceed- 
ingly tenacious  in  their  hold.  This  is  especially  the  case 
with  children,  whose  softer  mucous  membrane  probably 
adapts  itself  more  readily  to  the  action  of  the  suckers. 
Consequently,  although  yards  of  segments  may  be  re- 
moved by  means  of  an  ordinary  aperient,  the  small  head 
almost  invariably  remains  behind,  and  can  only  be  dis- 
lodged by  the  use  of  special  precautions. 


244 


WORMS 


In  all  cases  of  tape- worm,  the  alimentary  canal  contains 
a  great  excess  of  mucus,  which  protects  the  head  of  the 
worm  from  the  action  of  the  anthelmintic  as  this  passes 
clown  the  bowel.  For  some  time,  therefore,  before  special 
treatment  is  had  recourse  to,  the  child  should  be  put 
upon  a  non-farinaceous  diet,  as  recommended  in  the  pre- 
vious chapter,  so  as  to  diminish  the  amount  of  mucus,  and 
as  far  as  possible  correct  this  derangement  of  the  boAvels. 
For  the  week  immediately  preceding  the  administration 
of  the  vermifuge,  the  child  should  be  forbidden  even 
bread,  and  should  take  as  a  substitute  Dr.  Camplin's  bran 
biscuits  or  the  more  palatable  French  gluten  bread.  It  is 
well  also,  as  Dr.  Leslie  Ogilvie  has  advised,  to  administer 
a  dose  of  aperient  salts  on  several  successive  mornings 
before  the  treatment  is  begun.  After  this  preparation, 
the  anthelmintic  may  be  given  with  some  prospect  of 
success.  The  favourite  drug  for  this  purpose,  and  pro- 
bably the  most  effectual  one  for  ordinary  cases,  is  the 
liquid  extract  of  male  fern.  The  quantity  required  is  con- 
siderable, but  as  its  action  is  solely  upon  the  worm,  a 
large  dose  may  be  given  to  young  subjects  without  hesita- 
tion, or  any  aj^prehension  of  doing  injury  to  the  child. 
The  remedy  is  best  administered  pure,  floating  upon 
peppermint  or  other  aromatic  water. 

The  mode  of  proceeding  is  as  follows,  and  if  the  child  be 
strong  enough  to  bear  the  necessary  fasting,  this  method 
seldom  fails  : — In  the  evening  a  dose  of  castor  oil  is  given. 
On  the  following  morning,  if  the  bowels  have  not  been 
relieved,  a  saline  aperient  is  to  be  administered.  After 
the  action  of  the  medicine  the  patient  is  ready  for  the 
special  treatment.  A  drachm  and  a  half  of  the  oil  of  male 
fern  is  divided  into  two  doses,  of  which  one  is  to  be  taken 
at  once  and  the  remainder  after  one  hour's  interval.  Then, 
after  waiting  another  three  hours,  a  second  dose  of  castor 
oil  is  to  be  given.  During  the  above  treatment  a  rigid 
abstinence  from  all  food  is  essential  to  success,  and  there- 


EXPULSION  OF  TAPE-WORM 


245 


fore,  from  before  the  first  dose  of  the  oil  until  after  the 
worm  has  been  expelled,  somewhere  about  the  middle  of 
the  following  day,  no  food  or  drink  can  be  allowed,  except 
occasional  sips  of  water  if  the  patient  is  thirsty.  It  is 
doubtful  whether  the  worm  be  killed  or  merely  stupefied 
by  the  action  of  the  remedy,  and  therefore  it  is  well  not 
^  to  delay  too  long  the  administration  of  the  second  dose  of 
castor  oil.  This  should  be  given  not  later  than  three  hours 
after  the  fern  extract.  Sometimes  the  nauseous  taste  of 
the  medicine  causes  vomiting.  In  such  cases  it  is  well  to 
quiet  the  stomach  beforehand  by  a  small  dose  of  laudanum 
or  morphia,  given  half  an  hour  before  the  administration 
of  the  anthelmintic.  The  morphia  acts  merely  as  a  seda- 
tive, without  interfering  in  any  way  with  the  special  action 
of  the  medicine. 

Another  successful  vermifuge  is  kamala,  which  may  be 
given  either  alone,  in  treacle,  or  made  up  into  a  draught 
in  combination  with  the  fern  extract.  Thus,  mix  up  a 
drachm  of  powdered  kamala  with  mucilage  until  an  emul- 
sion is  formed  :  then  add  a  drachm  and  a  half  of  fern 
extract  and  triturate  in  a  mortar,  gradually  adding  water 
to  make  a  three-ounce  mixture.  Dr.  Brunton  recommends 
this  to  be  given  after  a  fast  of  twenty-four  hours  in  the 
case  of  an  adult.  I  have  used  this  method  in  children  of 
seven  or  eight  years  old,  beginning  the  fast  after  a  mid- 
day dinner,  and  giving  the  draught  the  following  morning 
divided  into  two  doses  taken  at  an  interval  of  three  hours  ; 
and  have  found  the  treatment  well  borne.  Kamala  is  itself 
aperient,  and  this  method  does  not  usually  require  any 
additional  dose  to  effect  the  expulsion  of  the  dead  worm. 
If,  however,  the  creature  do  not  appear  within  four  hours 
of  taking  the  second  half  of  the  mixture,  a  tablespoonful 
of  castor  oil  may  be  given. 

A  favourite  remedy  on  the  Continent  is  a  decoction  of 
the  fresh  bark  of  pomegranate  root.  The  objections  to 
its  use  in  the  case  of  children  are  the  large  quantity  of 


246 


WORMS 


fluid  which  it  is  necessary  the  child  should  swallow,  and 
the  griping  pains  in  the  belly  which  are  apt  to  follow  the 
administration  of  the  drug.  M.  Collin,  who  has  given 
pomegranate  bark  largely,  states,  that  in  all  cases  where 
the  medicine  is  used,  the  dose  should  not  be  preceded  by 
a  purgative,  so  that  the  segments  may  not  be  separated 
from  the  head  of  the  worm.  To  prepare  the  decoction : — 
One  pint  of  water  is  added  to  an  ounce  of  the  fresh  bark, 
and  after  standing  for  twenty-four  hours,  this  quantity  is 
boiled  down  to  one-half.  The  decoction  is  then  divided 
into  three  parts,  which  are  all  to  be  taken  in  the  morning 
fasting,  with  an  interval  of  half  an  hour  between  each 
dose.  If  the  worm  does  not  come  away  in  three  hours, 
some  castor  oil  should  be  given  to  aid  its  expulsion.  The 
writer's  own  experience  of  pomegranate  bark  has  not  been 
encouraging,  but  M.  Collins  speaks  in  the  highest  terms  of 
this  method  of  treatment. 

Sometimes  in  children  great  difficulty  is  found  in  re- 
lieving the  patient  of  this  distressing  parasite,  and  dose 
after  dose  of  fern  extract  or  other  special  medicine  may 
be  given  without  dislodging  the  head  from  its  hold  of  the 
mucous  membrane.  In  all  such  cases  it  is  well  to  try 
the  effect  of  the  now  neglected,  but  not  the  less  valuable, 
vermifuge— oil  of  turpentine.  This  may  be  given  either 
in  one  large  dose,  or  in  frequent  smaller  quantities.  For 
a  large  dose,  three  to  four  drachms  is  given  in  the  morning 
after  the  usual  fast,  and  is  followed  in  three  hours  by  a 
spoonful  of  castor  oil  if  no  aperient  effect  has  been  already 
produced . 

The  plan  of  administering  the  remedy  in  repeated  small 
doses  has  been  strongly  advocated  by  Dr.  Davies.  For 
children  of  eight  years  of  age  and  upwards  he  recom- 
mends half  a  drachm  of  oil  of  turpentine,  with  an  equal 
quantity  of  honey,  to  be  administered  in  a  little  mucilage 
and  water  every  six  hours.  At  the  same  time  a  powder 
of  calomel,  with  compound  scammony  powder,  is  to  be 


TREATMENT 


247 


taken  every  second  morning.  Dr.  Davies  states  that  he 
has  never  known  taeniae  in  children  to  resist  this  treatment. 
A  drop  of  oil  of  peppermint  makes  the  turpentine  mix- 
ture more  palatable.  As  the  segments  grow  from  the  head, 
we  cannot  be  certain  that  the  entire  worm  has  been  ex- 
pelled unless  the  head  is  found.  This,  therefore,  should 
always  be  carefully  searched  for  in  the  excretions. 

To  fulfil  the  second  indication  of  destroying  the  nidus, 
recourse  must  be  had  to  the  measures  recommended  in 
the  preceding  chapter  (see  Mucous  Disease).  The  diet 
must  be  first  carefully  arranged,  so  as  to  cut  off  all  articles 
of  food  which  by  their  fermentation  would  give  rise  to 
acid,  and  so  favour  the  abnormal  secretion  of  mucus  in 
the  bowels.  Alkalies,  aloes,  &c.,  should  then  be  prescribed, 
as  has  already  been  directed. 

The  treatment,  however,  must  be  varied  according  to 
the  condition  of  the  stomach  and  bowels,  and  need  not  be 
pursued  in  all  its  details  in  every  case  of  worms.  If  there 
be  little  derangement  of  the  alimentary  canal,  purgatives 
or  injections  to  remove  the  worms,  followed  by  a  tonic, 
will  be  all  that  is  required.  It  is  only  in  cases  where  the 
secretion  of  mucus  is  in  great  excess,  and  the  interference 
with  digestion  and  assimilation  of  food  is  carried  to  a 
high  degree,  that  all  the  measures  given  above  are  re- 
quired. 

The  prolapsus  ani,  brought  about  by  the  great  straining 
excited  by  the  presence  of  worms,  usually  disappears  when 
the  worms  have  been  expelled.  Sometimes,  however,  it 
continues  for  weeks  as  a  consequence  of  irritation  at  the 
lower  part  of  the  rectum.  If  this  be  so,  the  prolapsed 
bowel,  after  each  action,  should  be  first  sponged  with  warm 
water,  then  painted  over  with  a  10  per  cent,  solution  of 
cocain,  and  be  returned  by  pressure  with  the  thumbs 
covered  with  a  soft  warm  napkin. 

Prolapse  may  often  be  prevented  by  placing  the  child 
during  defsecation  in  such  a  manner  that  his  feet  do  not 


248 


WORMS 


touch  the  ground,  and,  at  the  same  time,  the  edge  of  the 
anus  can  be  supported  by  two  fingers. 

The  bowels  must  be  carefully  regulated  so  as  to  prevent 
constipation  and  consequent  straining.  The  child  should 
be  warmly  clothed,  with  a  flannel  bandage  round  the  belly, 
and  should  take  frequent  exercise  in  the  open  air. 


CHAPTER  VIII 


TUBERCULOSIS 

CHILDREN  are  very  subject  to  tubercular  disease,  both 
ill  its  local  and  general  forms.  In  them  the  tubercu- 
lar infection  is  more  apt  to  pervade  the  system  generally 
than  it  is  in  the  adult ;  and  subacute  generalised  tubercu- 
losis is  a  frequent  cause  of  death. 

The  discovery  by  Koch  of  the  tubercle  bacillus  has  so 
transformed  the  pathology  of  tuberculosis  that  the  views 
formerly  held  as  to  the  incidence  of  the  disease,  and  in 
particular  as  to  the  influence  of  heredity,  have  undergone 
considerable  modification.  In  one  sense,  indeed,  the  dis- 
ease cannot  be  called  an  hereditary  one,  for  however  sus- 
ceptible the  child  may  be  to  the  bacillary  invasion,  and 
however  fatal  the  disease  may  have  proved  to  his  kindred, 
without  the  entrance  of  the  special  microbe  into  his  body 
he  cannot  become  tubercular.  On  the  other  hand,  there 
can  be  little  doubt  that  the  tissues  of  a  child  born  into  a 
consumptive  family  have  but  feeble  resisting  power  against 
the  inroads  of  the  infecting  agent,  so  that  he  falls  an  easy 
victim  to  its  attacks.  In  this  sense  the  child  may  be  said  to 
have  an  hereditary  proneness  to  the  disease.  Again,  as 
Cohnheim  suggested,  an  infant  may  be  born  already  infected 
with  the  bacillus,  which  remains  dormant  for  months  or 
years  until  roused  into  activity  by  insanitary  conditions  or 
other  agencies  adverse  to  health.  This  theory  may  explain 
cases  of  foetal  tuberculosis,  or  of  the  complaint  affecting 
new-born  infants ;  but  such  a  source  for  the  disease  is 
admittedly  an  exceptional  one. 


250 


TUBERCULOSIS 


The  microbe  may  enter  the  body  at  any  point,  but  in 
ordinary  cases  infection  takes  place  either  by  the  air- 
passages  or  by  the  alimentary  canal.  If  by  the  air- 
passages  the  bacillus  must  be  drawn  in  with  the  air ;  but 
all  observers  agree  that  contamination  of  the  air  by  exhala- 
tions from  the  lungs  of  phthisical  patients  is  so  feeble  as 
to  be  practically  of  no  account.  All  experiments  tend  to 
show  that  the  bacillus  is  derived  from  dried  sputum, 
which,  becoming  pulverised,  is  diffused  through  the  dust 
of  a  room,  and,  as  dust,  is  drawn  with  the  air  into  the 
lungs.  Some  children,  no  doubt,  become  infected  in  this 
way,  but  in  the  large  majority  of  cases  it  is  by  the  alimen- 
tary canal  that  the  microbe  obtains  admittance  in  early 
life.  Milk  forms  a  large  part  of  a  child's  diet,  and  milk 
drawn  from  a  tuberculous  udder  has  been  shown  to  be  ex- 
ceptionally virulent.  This,  probably,  is  the  commonest 
source  of  infection.  Again,  young  children,  as  Dr.  Dawson 
Williams  reminds  us,  are  in  the  habit  of  putting  into  their 
mouths  any  object  they  may  pick  up  from  the  floor,  and 
by  this  practice,  no  doubt,  increase  their  chances  of  tuber- 
cular infection. 

But  before  entering  the  air-passages  proper  or  the  ali- 
mentary canal  the  bacillus  may  be  intercepted  earlier  in  its 
course  while  still  in  the  pharynx.  Dr.  Woodhead,  in  1894, 
expressed  the  opinion  that  the  organisms  maybe  taken  up 
by  the  lymphoid  tissue  of  the  tonsils  and  pharynx  and  carried 
to  the  cervical  lymphatic  glands  without  there  being  present 
any  lesion  of  mucous  membrane.  In  the  following  year 
M.  Dieulafoy  conducted  some  inoculation  experiments 
which  tended  to  confirm  this  opinion.  Kecently  Dr.  Hugh 
Walsham  has  published  a  series  of  interesting  observations 
which  show  that  without  symptoms  pointing  to  the  tonsils 
these  organs  may,  and  if  the  lungs  are  affected  probably 
do,  contain  miliary  and  caseous  nodules  scattered  through 
their  substance. 

But  whether  they  enter  by  the  tonsil  or  the  alimentary 


MODE   OF  INFECTION 


251 


tract  the  bacilli  are  taken  up  by  wandering  lymphoid 
corpuscles  and  the  struggle  begins.  In  a  sturdy  child  the 
leucocytes  can  probably  deal  satisfactorily  with  a  moderate 
invasion  of  the  microbes,  and  the  latter  are  destroyed. 
But  in  a  child  with  low  resisting  power,  or  in  a  healthy  one 
if  the  microbes  are  very  numerous,  the  intruding  organisms 
may  gain  the  victory  and  be  carried  unharmed  by  the  cells 
to  the  nearest  chain  of  lymphatic  glands.  By  this  means 
the  lymphatic  glands  in  the  neck  and  the  mesenteric 
glands  in  the  belly  may  become  the  seat  of  tuberculous  en- 
largement. But  it  is  not  always  the  first  set  of  glands 
which  become  affected.  In  the  neck  the  microbes  may  pass 
the  cervical  glands  and  settle  in  those  of  the  anterior 
mediastinum,  leading,  perhaps,  to  secondary  disease  of  the 
lungs.  In  the  abdomen  Dr.  Woodhead  has  been  able  to 
trace  the  course  of  the  organism  through  the  glands  of  the 
mesentery  to  those  behind  the  peritoneum,  and  thence 
through  the  diaphragm  to  the  posterior  mediastinal  and 
bronchial  glands,  and  -eventually  to  the  lung. 

In  the  case  of  the  respiratory  passages,  when  intro- 
duced by  the  air,  the  microbes  become  arrested  in  the 
alveoli  or  terminal  bronchioles.  Here  they  determine  a  cell 
growth  which  pervades  the  peri-bronchial  tissue,  and  sets 
up  a  little  patch  of  peri-bronchitis  or  broncho-pneumonia. 

When  the  microbe  has  obtained  admittance  into  the 
body,  the  degree  and  form  of  disease  that  follows  is  very 
variable.  The  virulence  of  the  organism,  the  intensity  of 
the  dose,  the  susceptibility  of  the  child,  and  the  healthy  or 
other  conditions  in  which  he  is  being  reared,  all  have  their 
influence  in  determining  the  issue.  The  degree  of  disease 
set  up  is  no  doubt  largely  a  question  of  dose,  but  the  more 
susceptible  the  child  the  smaller  will  be  the  dose  required 
to  produce  a  corresponding  effect.  In  former  days  much 
was  said  and  written  of  the  tuberculous  diathesis,"  a 
special  type  of  constitution  which  was  held  to  be  a  family 
inheritance,  and  tended  to  favour,  if  it  did  not  actually  in- 


252 


TUBERCULOSIS 


duce,  the  formation  of  tubercle.  The  presence  of  this 
diathesis  was  indicated  by  certain  pecuHarities  of  face  and 
figure.  Although  in  these  days  less  is  said  than  formerly 
on  this  subject,  yet  to  deny  that  children  of  this  type  have 
a  lessened  power  of  resisting  the  invasion  of  the  microbe 
is  surely  to  reject  the  teaching  of  all  clinical  experience. 
Such  children  are  tall  for  their  age  and  slightly  made  ; 
the  skin  is  delicate  and  transparent  looking,  allowing  the 
superficial  veins  to  be  distinctly  seen ;  the  face  is  oval  and 
the  features  generally  are  regular.  These  children  are  often 
remarkably  good-looking,  with  large,  bright,  intelligent 
eyes,  long  eyelashes,  and  soft  silken  hair.  The  limbs  are 
straight,  the  wrists  and  ankles  small ;  the  nervous  system 
is  highly  developed  and  the  general  organisation  delicate. 
The  teeth  are  cut  betimes  ;  they  walk  and  talk  early ;  and 
the  f ontanelle  often  closes  before  the  end  of  the  second  year. 

There  is  another  variety  of  physical  conformation  which 
used  to  be  held  to  constitute  the  scrofulous  type.  It  is, 
however,  as  subject  as  the  preceding  to  tuberculous  mani- 
festations, but  these  tend  rather  to  assume  the  form  of 
disease  of  the  bones  and  joints,  lesions  which  used  to  be 
called  strumous,"  but  are  now  known  to  be  tubercular. 
They  may  lead,  indeed,  to  every  variety  of  tubercular  infec- 
tion. In  this  type,  the  face  is  more  rounded  than  oval ; 
the  complexion  is  dull  and  pasty-looking,  the  skin  thick 
and  opaque.  The  face  is  not  so  comely  as  in  the  last  type, 
although  it  is  by  no  means  necessarily  ill-favoured.  The 
features  are  large,  the  lips  full,  the  alse  of  the  nose  thick, 
the  nostrils  expanded  so  that  the  nose  looks  broad.  The 
tongue  is  often  large.  The  ends  of  the  long  bones  are  full 
and  their  shafts  thick.  The  fingers  may  be  clubbed.  The 
belly  is  large  and  prominent.  In  these  children  there  is 
great  activity  of  all  the  epithelial  structures.  The  hair 
and  nails  grow  rapidly  ;  the  skin  generally  is  rough  and 
scaly  ;  and  there  is  often  a  remarkable  development  of  hair 
which  is  seen  as  a  thick  down  on  the  forehead,  cheeks,  ears, 


METHOD  OF  EXTENSION 


253 


shoulders  and  down  the  spine.  There  is  over- secretion  from 
the  nose  ;  the  skin  about  the  lips  is  subject  to  crack  and 
become  sore ;  the  eyes  often  look  weak  even  when  not  in- 
flamed ;  and  there  is  a  great  tendency  to  ophthalmia,  in- 
flammation of  tarsi,  catarrhs,  certain  skin  diseases,  to  caries 
of  bone,  and  to  a  low  form  of  pneumonia. 

Although  these  several  types  present  certain  contrasted 
features,  each  must  be  regarded  as  disposing  to  tubercular 
infection,  for  although  in  the  latter  the  disease  tends, 
perhaps,  to  run  a  more  chronic  course,  the  children  of 
either  type,  when  attacked,  may  exhibit  any  of  or  all  the 
consequences  due  to  the  entrance  of  the  tubercle  bacillus 
into  the  body.  But  in  addition  to  this  constitutional 
vulnerability  of  organs,  the  child's  resisting  power  may  be 
lowered  by  all  the  various  causes  which  are  able  to  impair 
the  general  health.  Thus,  previous  disease,  especially  the 
infectious  fevers ;  insanitary  surroundings,  such  as  dirt 
and  faulty  ventilation ;  privation  generally ;  mental  suffer- 
ing and  distress ;  all  these  tend  materially  to  weaken  the 
defensive  power  of  the  system. 

But  although  deficient  resisting  power  may  increase  a 
child's  chances  of  infection,  normal  energy  in  defence  may 
not  protect  him  if  the  dose  be  adequate.  This  extension 
to  other  organs  may  occur  by  actual  contact,  as  when  the 
lung  takes  on  the  disease  from  a  lymphatic  gland  which 
touches  its  surface.  The  gland  softens  and  ulcerates 
through  the  wall  of  a  small  bronchus  or  little  blood- 
vessel. In  the  first  case  it  infects  the  lung  only ;  in  the 
second  its  bacilli  are  distributed  by  the  current  of  blood 
to  all  parts  of  the  body.  It  is  more  common,  however,  for 
the  organisms  to  spread  from  a  more  distant  focus,  whence 
they  are  conveyed  to  other  parts  by  the  lymphatics  and 
blood-vessels.  In  infants,  in  whom  a  generalised  acute  or 
subacute  tuberculosis  is  a  common  cause  of  death,  the 
microbes  are,  no  doubt,  dispersed  over  the  body  by  this 
means. 


254 


TUBERCULOSIS 


The  varieties  of  tuberculosis  which  will  be  considered 
are : — 

Greneral  subacute  tuberculosis  of  infants. 
Chronic  pulmonary  tuberculosis. 
Tuberculosis  of  glands. 

General  Subacute  Tuherculosis  of  Infants. 

This  variety  of  the  disease  may  be  met  with  at  any  period 
of  infancy,  but  for  the  first  few  months  after  birth  is  com- 
paratively rare.  It  gets  more  and  more  common,  however, 
as  time  goes  on,  and  after  the  age  of  six  months  is  a  fre- 
quent cause  of  wasting  and  death.  In  the  majority  of 
cases  the  bacilli  are  conveyed  by  tuberculous  milk,  and 
reach  the  system  through  the  medium  of  the .  alimentary 
canal. 

Pathology. — In  a  generalised  tuberculosis  the  granula- 
tions are  widely  scattered,  and  may  be  found  after  death 
in  most  of  the  organs  of  the  body.  As  a  rule,  the  lungs, 
liver,  spleen,  lymphatic  glands,  and  pia  mater  suffer  most 
commonly  and  severely ;  but  no  part  of  the  body  can  be 
said  to  be  exempt,  although  some  organs  are  attacked  so 
seldom  that  tuberculosis  in  them  is  regarded  as  a  patho- 
logical curiosity.  Thus,  in  the  gullet,  the  stomach,  and 
duodenum  the  disease  is  rare ;  but  the  rest  of  the  alimen- 
tary canal  is  a  common  seat  for  the  granulations,  especially 
the  neighbourhood  of  Peyer's  patches.  The  focus  or  point 
from  which  the  infection  proceeds  may  often  be  noticed  as 
a  minute  ulcer  on  the  mucous  membrane  of  the  bowel,  or 
a  caseous  nodule  in  a  Peyer's  patch,  or  a  cheesy  lymphatic 
gland.  Sometimes,  however,  no  such  lesion  can  be  dis- 
covered, for,  as  in  the  case  of  the  tonsil,  the  microbes  may 
make  their  way  through  the  mucous  membrane  and 
lymphatic  glands  in  connection  with  it,  and  leave  no  trace 
behind.  From  this  point  of  entrance  they  may  pass  at 
once  into  the  circulation,  by  way,  perliajDS,  of  the  lacteal^ 


SYMPTOMS 


255 


duct,  and  be  swept  off  to  distant  parts  of  the  body. 
Whether  the  disease  set  up  is  to  be  general  or  merely 
local  i^robablj  depends  upon  the  size  of  the  dose.  If  the 
microbes  are  numerous  they  may  affect  many  organs ;  if 
few,  the  lesions  they  bring  about  are  more  limited,  so  that 
the  first  sign  of  disease  may  arise  from  a  single  joint,  a 
bone,  or  the  membranes  of  the  brain. 

Symptoms. — Infants  who  suffer  from  this  form  of  tuber- 
culosis often  present  features  which  even  at  this  early  age 
can  be  recognised  as  characteristic.  They  are  slim  in 
build  and  small  boned ;  their  teeth  are  cut  early,  the  first 
incisor  often  coming  through  in  the  course  of  the  fifth  or 
sixth  month  ;  the  fontanelle  is  moderately  open ;  the  eye- 
brows and  eyelashes  are  well  developed,  and  on  their 
shoulders  and  S23ines  we  often  see  a  thick,  fine  down.  The 
disease  begins,  as  a  rule,  very  gradually.  The  child  takes 
his  food  eagerly,  but  is  noticed  to  get  gradually  thinner, 
although  his  appetite  is  good  and  his  stools  are  in  every 
way  normal.  His  food,  they  say,  does  him  no  good.  As  a 
rule  he  is  not  peevish  or  fretful,  for  he  is  not  in  pain. 
There  is  no  sign  of  flatulence  or  abdominal  discomfort,  but 
the  fat  gradually  disap^Dcars  from  his  body,  his  muscles 
waste,  his  face  gets  pinched  and  old-looking,  or  is  anxious 
as  if  he  were  loaded  with  care.  A  characteristic  sign  is  a 
slight  pitting  over  the  shin  bones  combined  with  an 
altered  state  of  the  skin,  which  will  be  noticed  to  be  dry, 
dingy-looking,  and  absolutely  inelastic.  This  inelasticity 
of  skin  is  a  not  uncommon  symptom  in  wasting  babies,  and 
is  rarely  absent  in  infants  who  suffer  from  severe  purging ; 
but  when  combined  with  slight  j)itting  over  the  tibiae  and 
a  complete  want  of  symptoms  pointing  to  any  fault  in  the 
digestive  processes  it  ought  to  give  rise  to  reflection.  The 
urine  in  these  cases  has  been  said  to  be  albuminous.  It  is 
difiicult  to  collect  the  urine  in  young  infants,  but  in  cases 
of  the  kind  where  I  have  succeeded  in  doing  so  I  have  not 
found  albumen.    I  think,  too,  it  is  exceptional  to  note  any 


256 


TUBERCULOSIS 


marked  enlargement  of  the  liver  or  spleen :  indeed,  until 
we  approach  the  end  of  the  period  of  infancy  it  is  uncom- 
mon to  find  signs  of  tubercular  mischief  connected  with 
any  particular  organ.  It  is  rare  for  the  lungs  to  show 
evidence  of  consolidation  or  for  the  abdomen  to  swell  from 
tubercular  inflammation  of  the  peritoneum.  Later,  how- 
ever, especially  towards  the  end  of  the  second  year,  distinct 
implication  of  organs  becomes  more  common,  and,  as  in 
older  children  who  suffer  from  tuberculosis,  we  may  find  a 
hard,  swollen  spleen,  or  spots  of  consolidation  at  the  apices 
or  elsewhere  in  the  lungs,  or  signs  of  tubercular  peri- 
tonitis. 

The  temperature  may  be  normal  for  days  together,  and 
if  occasionally  elevated  is  only  moderately  so,  seldom 
rising  higher  (in  the  rectum)  than  100' 5°.  But  in  simple 
wasting  the  bodily  heat,  as  a  rule,  is  sub-normal,  so  that  a 
rectal  temperature  of  99°  to  100°  in  an  infant  whose 
lowered  state  of  nutrition  cannot  be  explained  by  any  local 
derangement  is  a  symptom  of  no  little  importance.  It 
must  be  remembered  that  a  moderate  elevation  of  tempera- 
ture is  much  more  characteristic  of  tuberculosis  than  high 
fever.  A  marked  rise  in  the  thermometer  usually  points 
to  the  presence  of  a  catarrhal  complication.  It  suggests, 
too,  a  thorough  examination  of  the  ears  with  a  speculum 
and  reflected  light.  Many  of  these  infants  suffer  from 
otitis,  either  latent  or  accompanied  by  otorrhoea.  In  such 
cases  the  otitis  is  possibly  tiiberculous,  and  may  have  been 
the  immediate  cause  of  the  general  outbreak. 

Until  the  disease  is  advanced  there  is  rarely  any  sign  of 
local  derangement ;  or  if  any  such  disturbance  occur  it 
yields  readily  to  treatment.  Thus,  the  baby,  if  bathed 
carelessly  or  exposed  in  any  other  way  to  chill,  may  catch 
cold  like  any  other  infant  so  treated.  He  may  cough,  with 
signs  of  pulmonary  catarrh,  or  be  troubled  with  vomiting 
or  purging.  But,  as  a  rule,  these  catarrhal  derangements 
are  as  amenable  to  simple  remedies  as  if  the  infant  were 


DIAGNOSIS 


257 


not  the  subject  of  serious  disease.  Often  the  tuberculous 
complaint  runs  its  course  without  the  occurrence  of  any 
such  complication.  The  child  continues  to  dwindle.  His 
eyes  get  more  hollow  ;  his  face  more  pinched ;  his  expres- 
sion more  pitiful;  and  his  wrinkled  forehead  and  the 
deep  furrows  round  his  mouth  give  him  the  look  of  a  little 
old  man.  At  last  the  emaciation  becomes  extreme,  and  the 
child  dies  more  or  less  suddenly  from  pure  weakness,  with- 
out any  complication  having  arisen.  In  other  cases  death 
may  be  preceded  by  the  later  symptoms  of  tubercular 
meningitis  or  by  a  lung  complication  such  as  broncho- 
pneumonia. In  infancy  tubercular  meningitis  is  always  a 
secondary  complaint  occurring  at  the  close  of  a  general 
tuberculosis.  Under  the  age  of  two  years  it  is  most  rare  to 
meet  with  it  in  the  primary  form  such  as  is  common  in 
older  children.  The  same  may  be  said  of  tubercular  peri- 
tonitis, which  at  this  early  age  is  seldom  met  with  apart 
from  a  general  explosion  of  tubercle  over  the  body. 

Diagnosis. — In  this  variety  of  tuberculosis  the  diagnosis 
lies  rather  in  the  absence  of  the  symptoms  which  attend 
an  ordinary  case  of  marasmus  than  in  the  presence  of  any 
definite  signs  of  disease.  The  child  has  a  good  appetite 
and  takes  his  food  well,  but  continues  to  waste  persistently 
although  his  tongue  is  clean,  his  motions  are  normal  in 
frequency  and  appearance,  and  his  digestion  seemingly  in 
good  order.  In  a  case  of  infantile  atrophy  from  functional 
disorder,  the  child  vomits  or  suffers  from  diarrhoea,  or  his 
bowels,  if  not  actually  relaxed,  are  evidently  disturbed. 
The  motions  are  copious,  often  offensive,  and  are  composed 
mainly  of  undigested  food.  In  cases  such  as  these  there 
is  evidently  sufficient  interference  with  digestion  to  account 
for  the  failure  in  nutrition ;  and  we  are  not  forced  to  go 
beyond  what  we  see  and  search  for  a  deeper  cause.  But 
the  tuberculous  infant  wastes  although  no  sign  of  local 
disease  can  be  detected  or  any  failure  in  the  digestive  pro- 
cesses.   We  have,  therefore,  to  fall  back  for  an  explanation 

17 


258 


TUBERCULOSIS 


upon  some  underlying  condition;  and  if  we  find  a  dry, 
inelastic  skin,  and  slight  pitting  of  the  legs,  we  are  justified 
in  taking  a  very  gloomy  view  of  the  child's  chances  of 
recovery. 

The  diagnosis  becomes  more  difficult  in  cases  where 
temporary  attacks  occur  of  digestive  derangement,  for 
these  may  be  held  to  account  sufficiently  for  the  failure  in 
health.  But  here  the  results  of  treatment  aiford  a  very 
important  means  of  estimating  the  nature  of  the  illness. 
Thus,  if  the  diet  be  reconsidered  and  the  nursery  arrange- 
ments altered,  and  the  child  begins  at  once  to  improve,  the 
absence  of  tubercle  becomes  exceedingly  probable. 

The  greatest  difficulty  occurs  in  cases  where  we  find  the 
child  suffering  from  some  temporary  disturbance  which 
raises  the  temperature  of  the  body.  In  an  uncomplicated 
case  the  temperature,  as  has  been  said,  is  normal  or  only 
very  moderately  elevated ;  but  still  we  cannot  venture  at 
once  to  exclude  tuberculosis  because  the  rectal  temperature 
is  high.  We  have  to  search  for  the  cause  of  the  fever  and 
consider  whether  this  in  itself  is  sufficient  to  account  for 
the  infant's  state.  Our  first  care,  of  course,  should  be  to 
examine  the  mouth  for  signs  of  teething ;  but  after  the 
mouth  all  parts  of  the  body,  not  forgetting  the  ears,  must 
be  subjected  to  careful  scrutiny.  As  long  as  there  is  an 
adequate  cause  to  account  for  the  illness,  we  are  not  jus- 
tified in  making  a  diagnosis  of  tuberculosis,  although  a 
history  of  prolonged  wasting  in  a  child  whose  family  ten- 
dencies are  not  free  from  suspicion,  should  make  us  cautious 
in  expressing  an  opinion.  Progressive  emaciation  in  an 
infant  whose  appetite  is  good,  and  digestion  not  obviously 
at  fault,  is  a  highly  suspicious  symptom  ;  and  teething,  or 
a  complication  such  as  otitis,  which  does  not,  as  a  rule, 
give  rise  to  serious  interference  with  nutrition,  cannot  be 
held  to  explain  sufficiently  the  child's  serious  state  :  indeed, 
if  accompanied  by  persistent  wasting,  otitis  is  an  argument 
rather  in  favour  of  tuberculosis  than  against  it. 


DIAGNOSIS 


259 


There  is  one  other  general  disease  which  may  be  possibly 
confounded  with  tuberculosis.  This  is  inherited  syphilis. 
In  certain  cases  of  that  transmitted  disease  (see  p.  185), 
general  wasting  occurs  without  any  sign  of  local  mischief, 
or  any  symptoms  characteristic  of  the  complaint.  But  in 
a  syphilitic  baby  the  failure  of  nutrition  is  less  extreme ; 
the  skin  is  excessively  pallid  or  has  the  peculiar  cafe-au-lait 
tint ;  the  eyebrows  and  eyelashes  are  scanty  or  absent  in- 
stead of  luxuriant ;  the  fontanelle  is  large  instead  of 
small;  the  occipital  glands  can  usually  be  felt,  and  we  can 
often  detect  craniotabes.  Moreover,  a  syphilitic  child  is 
generally  restless  and  uneasy,  especially  at  night,  while  a 
tuberculous  baby,  if  he  is  only  fed  wisely  and  with  regu- 
larity, will  often  lie  for  hours  without  making  any  com- 
plaint. Lastly,  an  enquiry  of  the  mother  as  to  miscar- 
riages and  as  to  the  health  of  her  previous  children  will 
help  us  greatly  in  reaching  a  conclusion. 

As  long  as  our  doubts  continue  as  to  the  nature  of  the 
illness  we  should  make  repeated  examination  of  the  various 
organs,  especially  of  the  lungs,  to  detect  the  earliest  signs 
of  local  mischief ;  for  spots  of  consolidation  forming  at 
the  apices  or  elsewhere  about  the  chest  would  point  very 
decidedly  to  tuberculosis. 

Still,  when  all  is  said,  the  diagnosis  of  subacute  general- 
ised tuberculosis  in  infants  must  often  be  a  very  difficult 
matter.  In  many  cases  there  is  so  much  room  for  doubt 
that  it  is  wise  to  be  cautious  in  expressing  a  positive 
opinion.  Amongst  well-to-do  children  where  the  family 
tendencies  can  be  ascertained,  and  we  can  be  sure  that  the 
infant  has  been  fed  with  judgment  and  tended  with  care, 
there  is  less  liability  to  error.  In  a  family  of  known 
consumptive  proclivities  a  baby  wastes  in  spite  of  treat- 
ment ;  the  stools  are  healthy  looking  and  his  food  is  appar- 
ently well  digested.  Here,  if  we  can  exclude  syphilis, 
the  probabilities  in  favour  of  tuberculosis  are  strong.  If, 
in  addition,  we  find  slight  pitting  of  the  legs  on  pressure. 


260 


TTTBERCULOSIS 


we  are  justified  in  entertaining  the  most  serious  apprehen- 
sions. On  the  other  hand,  when  the  conditions  of  life  are 
uncertain,  and  in  poor  families  where  the  infant  has  been 
half  starved  and  exposed  to  all  kinds  of  privation,  a  consti- 
tutionally healthy  child  may  be  reduced  by  simple  mal- 
nutrition to  a  state  of  extreme  weakness  and  emaciation. 
In  such  a  case  we  may  well  hesitate ;  but  the  presence  of 
large  quantities  of  undigested  curd  in  the  motions  would 
account  in  a  measure  for  the  child's  loss  of  flesh,  and  the 
absence  of  pitting  of  the  legs  on  pressure  would  give  us 
further  encouragement.  Still,  the  likeness  to  tuberculosis 
is  exceedingly  close,  and  it  is  prudent  to  reserve  an  opinion 
until  we  have  had  an  opportunity  of  seeing  the  effect  of 
treatment.  Many  an  infant  who  has  been  condemned 
as  tubercular  has  shown  a  surprising  improvement  and 
quickly  recovered  under  the  influence  of  warmth  and  rest 
and  a  well-chosen  dietary. 

Prognosis.  — When  a  subacute  general  tuberculosis  is  esta- 
blished in  the  infant  no  treatment  can  be  expected  to  suc- 
ceed. We  may  put  a  stop  to  intercurrent  derangements, 
such  as  attacks  of  vomiting  or  looseness  of  the  bowels,  and  in 
that  way  postpone  the  end ;  but  in  the  present  state  of  our 
knowledge  there  is  no  known  remedy  which  will  arrest  or 
delay  the  natural  course  of  the  complaint.  Much,  then, 
must  depend  upon  the  opinion  we  have  formed  as  to  the 
nature  of  the  illness.  As  long  as  we  are  in  doubt  we  may 
continue  to  hope  for  improvement ;  but  when  we  have 
satisfied  ourselves  as  to  the  tuberculous  nature  of  the 
disease  we  can  only  anticipate  one  result. 


CHAPTER  IX 


TUBELIOULOSIS   OP  THK  LUNGS 

young  children  pulmonary  tuberculosis  presents  very 
special  characters.  The  chronic  form,  with  which  alone 
we  have  here  to  deal,  is  rarely  seen  in  infancy.  It  becomes 
more  common  as  life  advances,  but  it  is  not  until  the  later 
period  of  childhood  is  reached  that  the  complaint  often 
shows  itself  in  the  form  which  is  so  familiar  to  us  in  the 
case  of  the  adult.  In  the  young  child,  although  we  may 
find  the  granulations  collected  at  the  apices  as  is  the  rule 
in  older  persons,  they  are  often  scattered  irregularly  over 
the  lungs,  so  that  the  apices  may  be  free  while  the  lower 
lobes  are  more  or  less  widely  solidified.  In  many  of  these 
cases,  no  doubt,  the  disease  is  derived  directly  from  a 
caseous  bronchial  gland  in  actual  contact  with  the  pul- 
monary tissue,  and  therefore  starts  from  the  root  of  the 
lung;  but  another  explanation  of  the  peculiarity  lies  in 
the  fact  that  in  early  life  pulmonary  phthisis  often 
succeeds  to  an  attack  of  bronchitis  or  broncho-pneumonia. 
In  cases  where  the  disease  follows  measles  this  is  almost 
invariably  the  course  of  events.  The  attack  of  measles  is 
complicated  with  broncho-pneumonia,  and  the  patient  is 
left  with  a  consolidation  at  the  base  of  the  lung  which 
although  at  first  simple  may  afterwards  become  tuber- 
cular through  infection  with  the  special  bacillus. 

Pathology. — The  microbes  may  enter  the  lung  directly 
or  indirectly.    They  may  be  drawn  in  with  the  air  or  may 


262 


TUBERCULOSIS  OF  THE  LUNGS 


be  carried  to  the  chest  from  a  distant  part  of  the  body. 
The  point  of  entrance  or  focus  from  which  infection 
proceeds  may  be  a  tubercular  gland  in  the  neck  or  else- 
where, a  circumscribed  patch  of  disease  in  bone  or  joint, 
or  a  minute  ulcer  of  mucous  membrane.  When  thus 
derived  from  a  point  of  infection  in  the  patient's  own 
body  the  germs  may  spread  thence  to  the  lung  by  actual 
contact,  or  reach  it  through  the  medium  of  the  lymphatics 
or  blood-vessels.  When  the  neighbourhood  of  the  root  is 
the  first  part  of  the  lung  to  be  attacked  the  disease  is 
probably  derived  from  a  tuberculous  bronchial  gland 
which  is  surrounded  more  or  less  completely  by  pulmonary 
tissue.  The  gland  undergoes  caseation  and  softening  and 
poisons  the  lung  tissue  in  contact  with  it,  so  that  the  wall 
of  a  small  air-tube  or  the  coats  of  a  little  blood-vessel  take 
on  the  same  process  and  become  infected  with  the  bacillus. 
By  this  means  the  microbes  pass  into  the  air-passage  or 
blood-current  and  are  scattered  through  the  lung.  So, 
also,  when  the  focus  is  seated  at  a  point  more  distant  from 
the  chest  it  is  through  the  medium  of  the  blood-vessels  in 
most  cases,  and  by  similar  means,  that  infection  is  con- 
veyed. The  extent  of  injury  to  the  lung  is  no  doubt  fixed 
by  the  size  of  the  dose.  A  large  number  of  germs  will  be 
dispersed  widely  producing  scattered  lesions;  a  small 
number  will  give  rise  merely  to  a  circumscribed  nodule. 
In  either  case  the  microbes  become  arrested  in  the  minute 
vessels  ramifying  on  the  vesicles  and  induce  a  cell  pro- 
liferation, at  first  in  the  wall  of  the  capillaries  and  after- 
wards in  the  cavity  of  the  cell. 

When  the  microbes  are  drawn  into  the  lung  with  the 
dust  in  the  inspired  air  a  little  patch  of  peri- bronchitis  or 
broncho-pneumonia  is  set  up  by  the  arrest  of  the  germs  in 
the  alveoli  or  terminal  bronchioles.  In  this  way  one  lobule 
or  many  may  be  involved ;  and  if  the  dose  of  the  infecting 
agent  be  large,  extensive  consolidations  may  be  induced. 
Thus,  we  may  find  a  whole  lobe  or  even  the  complete  lung 


SYMPTOMS 


263" 


to  be  converted  into  a  solid  mass  by  closely  packed  tuber- 
culous nodules.  When  once  set  up  the  tubercular  process 
tends  to  spread  at  its  circumference  so  as  to  involve  more 
and  more  of  the  organ.  The  changes  it  passes  through 
are  the  same  in  the  child  as  in  tbe  adult.  The  diseased 
tissue  may  undergo  caseation  and  softening,  or  may  be 
converted  into  a  fibrous  mass.  These  processes  are 
common  to  all  ages  and  need  not  be  discussed  here  in 
detail.  The  distinctive  features  of  phthisis  as  it  affects 
the  lungs  of  a  child  do  not  lie  in  any  special  peculiarity 
of  pathological  change,  but  are  to  be  found  in  the  un- 
familiar distribution  of  the  lesions  and  the  frequency  with 
which  the  bases  of  the  lungs  are  affected  and  the  apices 
are  free. 

Symptoms. — Although  the  discovery  of  the  tubercle 
bacillus  has  established  the  unity  of  phthisical  changes  in 
the  lungs,  yet  clinically  pulmonary  phthisis  may  be  seen 
to  fall  into  several  well-defined  types  according  to  the 
manner  in  which  it  begins.  There  is  the  primary  tuber- 
cular type,  in  which  mischief  is  discovered  at  the  apices  of 
the  lungs  and  granulations  are  scattered  more  or  less 
thickly  over  the  substance  of  the  organs.  There  is  the 
secondary  type,  in  which  the  disease  spreads  by  contact 
from  a  softening  bronchial  gland  or  is  grafted  upon  a 
broncho-pneumonia.  Lastly,  there  is  the  fibroid  form,  in 
which  a  lung  becomes  converted  wholly  or  partially  into  a 
mass  of  fibroid  tissue.  In  the  child  the  latter  variety  is 
rarely  a  consequence  of  grit  inhalation  in  the  course  of 
industrial  labour,  as  it  is  in  the  adult,  for  young  persons 
under  the  age  of  twelve  years  are  not  exposed  to  this 
source  of  illness.  In  early  life  fibroid  induration  of  the 
lung  is  usually  the  sequel  to  an  attack  of  broncho- 
pneumonia or  (more  rarely)  to  pleuritic  inflammation. 
It  is  often  present  in  conjunction  with  tubercular  disease 
and  may  arise  from  it,  but  it  may  also  have  an  in- 
dependent existence. 


264 


TUBERCULOSIS  OF  THE  LUNGS 


Pulmonary  phthisis  is  often  seen  in  connection  with  a 
flattened,  contracted,  or  otherwise  mis- shaped  chest ;  and 
in  families  which  have  a  marked  tendency  to  tubercle  the 
thorax  often,  perhaps  usually,  shows  some  deviation  from 
the  strictly  normal  type.  From  the  time  of  Gralen  a  small 
chest  has  been  recognised  as  constituting  a  special  pul- 
monary weakness,  for  a  small  chest  implies  small  lungs. 
The  lungs  being  small  the  thorax  is  obliged  to  adapt  itself 
to  the  size  of  its  contents.  The  ribs  become  unusually 
oblique,  the  chest  is  lengthened,  the  shoulders  fall,  and, 
as  a  consequence,  the  scapulae  project  backwards  at  their 
lower  angles  like  wings.  The  latter  deformity  has  given 
the  name  of  alar  or  pterygoid  to  this  variety  of  chest. 

A  thorax  so  elongated  does  not  necessarily  deviate  in 
any  other  particular  from  a  healthy  type.  The  antero- 
posterior and  lateral  diameters,  although  lessened  abso- 
lutely— for  the  chest,  as  has  been  said,  is  small — may  yet 
retain  their  normal  relative  proportions.  In  many  cases, 
however,  the  costal  cartilages  do  not  remain  firm ;  they 
consequently  yield  under  the  pressure  of  the  air  and 
become  straight,  and  the  antero -posterior  diameter  of  the 
thorax  is  diminished.  Aflat  chest  is  thus  produced  which 
may  or  may  not  be  combined  with  the  alar  deformity  of 
the  shoulder-blades. 

These  two  varieties  of  shape  of  the  thorax  may  be 
considered  to  indicate  a  pulmonary  weakness,  an  abnormal 
sensitiveness  to  unhealthy  impressions  which  goes  far  to 
encourage  the  development  of  the  phthisical  disorders.  In 
children  born  of  consumptive  parents  the  chest  is  very 
often  misshaped  in  the  manner  described. 

There  is  a  third  variety  which  is  a  form  of  the  pigeon- 
breasted  thorax.  It  may  be  found  in  a  healthy  child  born 
of  a  family  without  consumptive  history,  and  is  not 
distinctive  of  a  phthisical  tendency  although  it  usually 
shows  a  special  sensitiveness  to  changes  of  temperature. 
This  variety  is  the  result  of  adenoid  growths  in  the  naso- 


SYMPTOMS 


265 


pharynx.  The  ensiform  cartilage  is  depressed  so  as  in 
marked  cases  to  form  a  deep  pit  in  the  epigastrium.  At 
the  same  time  the  ribs  in  the  infra-mammary  region  on 
each  side  are  retracted,  so  that  the  breast-bone  at  its  lower 
end  is  forced  forwards  and  forms  a  distinct  prominence.  In 
childhood  symmetrical  retraction  of  the  infra-mammary 
regions  and  depression  of  the  ensiform  cartilage  are  due 
almost  invariably  to  naso-x)haryngeal  obstruction.  This 
variety  of  pigeon-breasted  thorax  is  distinguished  from  the 
pigeon-breast  we  so  often  see  in  rickets  by  the  difference 
in  shape  of  the  upper  part  of  the  chest  in  the  two  diseases. 
In  rickets,  where  all  the  ribs  are  soft,  the  whole  sternum 
projects,  and  the  chest  is  furrowed  laterally  as  high  as  the 
second  rib.  In  the  case  we  are  considering  the  protrusion 
is  confined  to  the  lower  end  of  the  breast-bone  and  the 
retraction  of  the  ribs  to  the  infra-mammary  region,  while 
at  the  upper  part  the  chest  is  flattened  from  before  back- 
wards. 

Although  it  is  common  to  find  the  chest  in  consumptive 
subjects  more  or  less  altered  in  shape,  as  above  described, 
it  does  not  necessarily  exhibit  any  such  peculiarity. 
Phthisis,  unfortunately,  is  not  confined  to  children  who 
inherit  a  pulmonary  weakness.  In  early  youth,  as  in  after 
life,  a  serious  amount  of  disease  may  be  found  in  a  chest 
which  to  the  eye  presents  every  appearance  of  health. 

There  are  certain  general  symptoms  which  are  common 
to  all  forms  of  pulmonary  phthisis.  In  all  of  them 
nutrition  is  found  to  suffer.  The  child  looks  pale,  loses 
his  spirits,  and  becomes  listless  and  languid.  His  appe- 
tite is  capricious,  and  digestion  is  difficult  and  slow. 
He  wastes  with  more  or  less  rapidity ;  is  feverish  in  the 
night  and  often  in  the  daytime,  and  is  troubled  with 
frequent  cough.  But  while  these  symptoms  are  met  with 
in  all  forms  of  consumption  of  the  lungs,  in  different 
varieties  of  the  disease  they  are  found  to  vary  greatly  in 
intensity,  and  in  particular  cases  single  symptoms  may 


266 


TUBERCULOSIS  OF  THE  LUNGS 


be  absent  for  weeks  or  montbs  together.  Thus,  nutrition 
is  interfered  with  much  more  strikingly  in  some  cases 
than  in  others.  In  the  primary  tubercular  form  wasting 
takes  place  early,  and  the  loss  of  flesh  is  rapid  and 
extreme ;  while  in  fibroid  induration  of  the  lung,  unless 
the  disease  be  far  advanced,  or  be  complicated  by  an  inter- 
current inflammatory  attack,  nutrition  may  go  on  fairly 
well,  and  the  weight  of  the  body  be  but  little  reduced. 
Pyrexia,  again,  a  constant  symptom  when  the  disease  is 
primary,  often  subsides  for  a  time  when  the  tubercular 
mischief  is  grafted  into  a  pneumonic  consolidation,  and  in 
cases  of  uncomplicated  fibroid  induration  may  be  absent 
altogether. 

Cough  is  usually  one  of  the  first  signs  to  indicate  any 
affection  of  the  lungs :  but  in  pulmonary  phthisis  it  may 
be  comparatively  rare,  and  excite  little  notice  until  the 
disease  has  become  considerably  advanced.  In  the  begin- 
ning slight,  dry,  and  short,  it  becomes  after  a  time  moister 
and  more  prolonged ;  but  however  loose  the  cough  may 
be,  it  is  seldom  in  children  under  seven  or  eight  years  old 
accompanied  by  expectoration,  unless  vomiting  occur,  as 
such  children  almost  invariably  swallow  the  sputum  as  it 
reaches  the  mouth.  If,  however,  the  cough  produces 
vomiting,  large  quantities  of  purulent  mucus,  more  or  less 
thick  and  viscid,  may  be  expelled.  In  cases  of  fibroid 
induration  of  the  lung,  with  much  dilatation  of  the 
bronchi,  the  cough  may  assume  a  convulsive  character, 
like  the  cough  of  pertussis,  but  without  the  whoop.  The 
paroxysms  occur  at  long  intervals,  and  end  in  violent 
retching  efforts,  during  which  large  quantities  of  muco- 
purulent sputa  are  ejected.  Such  sputa  are  often  very 
viscid  and  stringy,  and  have  a  very  offensive  smell,  owing 
to  long  retention  in  the  dilated  air- tubes. 

Haemoptysis  is  a  rare  symptom,  as  the  blood,  like  the 
phlegm,  is  almost  always  swallowed.  Sometimes,  however, 
severe  hsemorrhage  may  occur  at  a  late  stage  of  the  disease, 


SYMPTOMS 


267 


causing  death.  This  is  seldom  seen  except  in  cases  com- 
plicated with  great  enlargement  of  the  bronchial  glands. 
In  infants  a  discharge  of  blood  from  the  lungs  is  hardly 
ever  seen.  In  children  of  seven  years  of  age  and  upwards, 
the  sputa  may  be  streaked  with  blood ;  but  haemoptysis, 
in  the  ordinary  sense  of  the  word,  is  uncommon,  and,  when 
it  occurs,  is  seldom  considerable. 

The  respirations  are  usually  increased  in  rapidity,  rising 
often  to  thirty,  forty,  or  even  more  in  the  minute.  This 
acceleration  is  not  necessarily  accompanied  by  any  feeling 
of  dyspnoea,  and  unless  the  structural  alterations  occupy 
the  greater  part  of  both  lungs,  is  seldom  the  cause  of  any 
discomfort  to  the  patient.  The  rate  of  breathing  is  always 
quickened  by  the  presence  of  pulmonary  catarrh,  and  is 
largely  influenced  by  the  temperature  of  the  body.  An 
increase  of  heat  necessarily  hastens  the  rapidity  of  breath- 
ing, for  more  carbonic  acid  is  formed,  and  more  oxygen  is 
required.  Rapid  breathing  may  also  be  an  early  sign  of 
tubercle  in  cases  where  the  physical  signs  are  as  yet 
unaffected.  If  unaccompanied  by  percussion-dulness  or 
bronchial  breathing,  it  is  said,  by  Niemeyer,  to  be  one  of 
the  first  and  most  important  symptoms  of  tubercular 
phthisis.  Also,  if  in  an  advanced  case  of  phthisis  the 
breathing  suddenly  becomes  rapid,  although  no  change  be 
noticed  in  the  physical  signs,  or  any  increase  in  the 
pyrexia,  we  may  strongly  suspect  that  rapid  extension  of 
the  disease  is  taking  place. 

Vague  chest  pains  and  uneasiness  about  the  shoulders 
are  sometimes  complained  of  by  children,  and  if  complained 
of  spontaneously  are  of  some  importance.  Such  pains 
seldom  last  long  at  a  time,  but  disappear  and  return 
irregularly. 

When  the  disease  is  advanced,  the  appetite  often  fails, 
but  not  always ;  it  may  continue  good  almost  to  the  last, 
and  the  more  chronic  the  case,  the  more  likely  is  the 
appetite  to  be  preserved.   A  considerable  degree  of  pyrexia 


268 


TUBERCULOSIS  OF  THE  LUNGS 


does  not  necessarily  destroy  this  relish  for  food — at  any 
rate  amongst  hospital  patients  ;  and  it  is  not  unusual  to  see 
a  child  eating  his  meals,  apparently  with  full  enjoyment, 
although  his  temperature  at  the  time  may  be  102°  or  103° 
Fahr.  The  habit  of  swallowing  the  sputum  is,  no  doubt, 
a  frequent  source  of  derangement  of  the  stomach;  and 
loss  of  appetite,  with  looseness  of  the  bowels,  and  other 
digestive  troubles,  must  be  frequently  attributed  to  the 
irritation  of  acrid  mucus  thus  imported  from  the  air- tubes 
into  the  alimentary  canal. 

Attacks  of  diarrhoea  are  very  common,  and  help  greatly 
to  reduce  the  weight  and  increase  the  feebleness  of  the 
patient.  If  these  attacks  appear  at  a  time  when  softening 
of  a  deposit  is  taking  place,  with  ulcerative  destruction  of 
lung  tissue,  and  continue  obstinate  in  spite  of  remedies, 
they  are  probably  due  to  tubercular  ulceration  of  the 
bowels. 

Emaciation  in  cases  of  phthisis  does  not  proceed  with 
any  regularity.  Sometimes,  even  in  the  primary  form,  the 
weight  of  the  body  remains  stationary  for  several  conse- 
cutive weeks,  or  even  undergoes  a  temporary  increase ;  but 
such  a  favourable  sign  is  exceptional  and  seldom  persists 
for  long  together.  When  the  disease  follows  a  broncho- 
pneumonia, wasting  is  by  no  means  a  constant  feature.  It 
is  determined  chiefly  by  the  degree  of  pyrexia,  the  state  of 
the  digestive  organs,  and  the  presence  or  absence  of  inflam- 
matory complications.  But  a  considerable  degree  of  fever 
will  not  necessarily  cause  emaciation  if  the  appetite  be 
good  and  the  digestion  active.  It  is  not  uncommon  to  see 
a  child  actually  gain  in  weight,  although  the  temperature 
stands  every  night  between  101°  and  102°  Fahr.,  and 
although  examination  of  the  chest  shows  that  the  pul- 
monary mischief  is  continuing  to  extend  itself.  In  fibroid 
induration  of  the  lungs,  which  in  an  uncomplicated  case 
is  not  attended  with  pyrexia,  the  amount  of  flesh  appears 
to  be  dependent  very  much  upon  the  state  of  the  weather, 


SYMPTOMS 


269 


and  consequently  upon  the  presence  or  absence  of  inter- 
current inflammatory  attacks.  Children  suffering  from 
this  form  of  consumption  are  generally  found  to  lose  in 
bulk  during  the  winter  when  catarrhs  are  acti\^e,  and  to 
regain  flesh  upon  the  return  of  more  genial  weather,  when 
their  liability  to  cold  is  diminished. 

In  all  cases  of  phthisis,  a  sudden  increase  in  the  rapidity 
of  wasting  combined  with  a  rise  in  the  temperature  is  a 
sign  of  the  occurrence  of  some  inflammatory  complication. 
To  an  attack  of  intercurrent  inflammation,  death  may  be 
usually  attributed ;  but  sometimes  it  is  a  consequence  of 
long-continued  fever,  sleeplessness,  and  malnutrition.  In 
such  cases  the  child  gets  gradually  weaker  and  thinner, 
and  at  last  can  hardly  be  persuaded  to  sit  up  in  his  bed 
even  to  take  food.  His  appetite  fails  completely  :  aphthae 
appear  upon  the  tongue,  gums,  and  inside  of  the  cheeks 
and  lips ;  the  lower  limbs  become  oedematous  from  the 
impoverished  state  of  the  blood  ;  and  death  ensues,  often 
preceded  by  very  distressing  dyspnoea. 

While  the  above  symptoms  are  common  to  all  forms  of 
consumption  of  the  lungs,  the  mode  of  beginning  and  the 
course  of  the  disease  differ  considerably  in  the  several 
varieties. 

In  chronic  primary  tubercular  phthisis,  the  beginning  is 
gradual.  From  the  first  the  general  health  suffers,  and 
throughout  the  general  symptoms  are  severe.  The  mother 
usually  complains  that  the  child  has  been  lately  growing 
languid  and  dull ;  that  his  appetite  has  failed,  and  that  he 
is  losing  flesh.  He  is  often  feverish  at  night,  and  is 
troubled  at  times  with  a  short  cough.  Cough  in  such  cases 
is  always  a  late  symptom,  and  is  preceded  by  signs  of 
general  disturbance  of  health. 

The  course  of  the  disease  is  comparatively  rapid,  and 
in  ordinary  cases  its  end  may  be  expected  within  eighteen 
months  of  the  first  appearance  of  the  physical  signs.  The 
child  continues  to  waste.    Pyrexia  is  usually  persistent, 


270 


TUBERCULOSIS  OF  THE  LUNGS 


and  is  accompanied  by  morning  sweats.  There  is  little 
desire  for  food.  The  digestive  organs  are  weak  and 
irritable  :  vomiting  is  frequently  excited  by  cough,  and 
the  bowels  are  disposed  to  be  relaxed.  The  voice  some- 
times becomes  hoarse  from  ulceration  of  the  larynx  (laryn- 
geal phthisis)  ;  but  this  symptom  is  less  common  in  young 
subjects  than  it  is  in  the  adult.  At  length  the  child  dies 
exhausted,  or  falls  a  victim  to  an  intercurrent  attack  of 
pulmonary  or  meningeal  inflammation. 

The  pneumonic  form  of  phthisis  may  either  follow  an 
acute  attack  of  broncho -pneumonia,  or  may  begin  more 
insidiously  by  the  extension  of  a  catarrh  from  the  smaller 
tubes  to  the  alveoli.  In  the  first  case  convalescence  is  slow 
and  uncertain.  The  pyrexia  does  not  subside  as  usual,  or, 
if  the  temperature  falls  at  first,  it  does  not  long  remain 
natural,  but  after  a  few  days  the  child  is  noticed  to  be 
again  feverish  at  night.  The  cough  continues ;  and,  in 
children  who  are  old  enough  to  expectorate,  the  sputa  may 
be  seen  to  be  streaked  with  blood,  although  this  is  excep- 
tional. Nutrition,  however,  may  go  on  fairly  well,  and  the 
patient  often  regains  weight,  or  at  any  rate  at  first  does 
not  sensibly  emaciate.  Such  symptoms  show  that  the 
unabsorbed  mass  left  after  the  attack  of  inflammation  of 
the  lung  has  undergone  cheesy  degeneration,  and  is  acting 
injuriously  upon  the  tissue  around,  setting  up  an  irritation 
which,  if  continued,  will  lead  to  breaking  down  of  the 
deposit.  But  it  must  be  remembered  that  these  symptoms 
do  not  always  follow  an  attack  of  pneumonia,  in  cases 
where  the  consolidating  material  has  failed  at  first  to  be 
reabsorbed.  So  long  as  a  cheesy  mass  remains  indolent 
and  untainted  by  the  special  microbe,  it  may  give  rise  to 
no  symptoms  at  all.  In  such  a  case,  in  young  subjects,  we 
may  still  hope  for  its  removal,  even  after  the  lapse  of  a 
time  which  would  have  rendered  so  favourable  a  result  in 
the  adult  impossible.  . 

The  occurrence  of  softening  is  usually  marked  by  a 


SYMPTOMS 


271 


sudden  increase  in  the  severity  of  the  general  symptoms. 
The  face  flushes ;  there  is  fever  at  night,  followed  by 
morning  perspirations ;  the  languor  and  weakness  are 
increased,  and  the  expression  of  the  child  becomes  dis- 
tressed and  careworn. 

In  cases  of  slow  development  of  pneumonic  phthisis, 
the  extension  of  a  catarrh  to  the  alveoli  from  the  smaller 
tubes  is  shown  by  a  rise  in  the  temperature.  The  child 
begins  to  be  feverish  at  night.  His  breath  becomes  short. 
His  cough  is  more  frequent,  drier,  harder,  and  more  dis- 
tressing, and,  if  there  is  any  expectoration,  the  phlegm 
may  be  streaked  with  blood.  These  special  symptoms, 
indicating  lung  irritation,  may  persist  for  a  considerable 
time  without  any  signs  being  noticed  of  general  impair- 
ment of  nutrition.  At  length,  however,  the  appetite  fails, 
digestion  suffers,  nutrition  is  interfered  with,  and  the  child 
wastes  perceptibly.  The  j)hysical  signs  which  accompany 
this  state  of  things  will  be  considered  afterwards,  but  it 
may  be  mentioned  here  that  although  apparently  trifling, 
they  are  not  the  less  important,  and  must  not  be  over- 
looked. 

Should  secondary  acute  tuberculosis  come  on,  all  the 
symptoms  are  aggravated.  Wasting  proceeds  with  rapidity ; 
the  feebleness  increases ;  appetite  is  completely  lost ;  and 
there  is  often  great  irritability  of  the  digestive  organs, 
with  vomiting  or  diarrhoea.  The  cough  becomes  more  dis- 
tressing, and  the  child  breathes  quickly,  and  often  pain- 
fully from  the  occurrence  of  dry  pleurisy.  Death  may  be 
preceded  by  squinting,  inequality  of  pupils,  convulsions, 
rigidity  of  joints,  and  other  symptoms  indicating  an 
advanced  stage  of  tubercular  meningitis. 

In  cases  of  fibroid  induration  of  the  lung,  there  may  be 
little  about  the  child  to  excite  attention  so  long  as  the 
disease  remains  in  an  early  stage.  Any  symptoms  which 
may  occur  are  the  result  merely  of  the  catarrhal  attacks 
to  which  such  a  condition  of  the  chest  renders  the  child 


272 


TTJBERCULOSIS  OF  THE  LUNGS 


peculiarly  prone.  In  the  interval  of  such  attacks,  the 
cough  disappears,  the  appetite  returns,  and  the  health  and 
strength  generally  appear  to  be  satisfactory.  It  is  when 
an  increase  in  the  cirrhosis  has  led  to  contraction  of  lung 
and  dilatation  of  bronchi  that  the  symptoms  become 
characteristic.  The  dilated  rigid  tubes  tend  to  retain 
their  secretions.  There  is  consequently  a  great  accumula- 
tion of  sputum,  which  putrefies,  and  is  only  with  great 
difficulty  evacuated.  The  cough  occurs  at  rare  intervals, 
in  paroxysms  lasting  ten  or  twenty  minutes,  or  even 
longer,  during  which  the  face  is  suffused,  the  eyes  become 
red  and  watery,  and  the  whole  appearance  is  suggestive 
of  a  severe  fit  of  whooping-cough.  At  the  beginning  of 
the  paroxysm  there  is  no  expectoration,  but,  after  a  time, 
stringy  muco-purulent  matter  begins  to  be  discharged ; 
and  the  fit  often  ends  in  violent  retching  efforts,  and  the 
expulsion  of  large  quantities  of  foetid  sputum.  Areolar 
fragments  of  elastic  tissue,  showing  ulceration  of  lung, 
may  be  often  detected  microscopically  in  the  expectorated 
matter. 

Owing  to  the  indurated  and  contracted  state  of  the 
lung,  its  circulation  is  more  or  less  impeded.  In  bad 
cases  there  is,  therefore,  some  hypertrophy  of  the  right 
side  of  the  heart,  and  a  prominence  of  the  superficial 
veins  in  the  neck,  chest,  and  limbs,  which  indicates  an 
abnormal  fulness  of  the  systemic  venous  system.  The 
fingers  soon  become  clubbed ;  and  the  face  has  habitually 
a  congested  turgid  appearance,  especially  when  the  patient 
is  suffering  from  a  superadded  catarrh. 

There  is  no  pyrexia  unless  catarrhal  pneumonia,  or 
ulceration  of  the  bronchial  tubes,  be  present,  as  in  the 
stage  called  fibroid  phthisis.  In  an  uncomplicated  case 
of  fibroid  induration  the  temperature  is  natural,  and 
perhaps  as  a  consequence  the  digestion  and  appetite 
are  good  as  a  rule,  and  the  appearance  of  the  child  is 
fairly  robust.    But,  after  the  disease  has  existed  for  some 


PHYSICAL  SIGNS 


273 


time,  the  constant  drain  upon  the  system,  produced  by  tlie 
copious  purulent  discharges  from  the  lungs,  very  com- 
monly gives  rise  to  amyloid  degenerations.  The  liver 
and  spleen  become  enlarged,  and  there  is  often  albumi- 
nuria with  oedema  of  the  extremities.  Moreover,  the  ex- 
tension of  the  disease  in  the  lung,  and  the  occurrence  of 
ulceration  (fibroid  phthisis),  prove  additional  sources  of 
weakness,  undermining  the  strength  of  the  patient.  Con- 
sequently, in  the  later  periods  of  the  disease,  the  child 
becomes  thin,  haggard-looking,  and  feeble.  His  debility  is 
increased  by  attacks  of  diarrhoea ;  and,  if  he  be  not  cut  oif 
by  an  intercurrent  pneumonia,  he  becomes  more  and  more 
prostrated,  and  eventually  dies  worn  out  and  exhausted. 

Physical  signs. — An  examination  of  the  chest  in  a  child 
must  be  conducted  with  as  much  care  as  if  the  patient  were 
an  adult.  To  do  this  effectually  it  is  important  that  he  be 
so  placed  as  to  occasion  no  difficulty  or  discomfort  to  the 
observer.  Infants  can  be  held  up  in  the  nurse's  arms  or 
be  raised  up  to  a  convenient  height  by  laying  them  upon  a 
cushion  placed  upon  the  table.  Older  children  may  be 
seated  upon  a  table  or  high  music  stool.  In  either 
case  the  patient  should  be  completely  stripped  to  the 
waist. 

In  young  subjects  the  physical  signs  present  certain 
peculiarities  which  it  is  important  to  be  prepared  for. 
Thus,  vocal  vibration  is  generally  altogether  absent,  both 
in  health  and  in  disease,  and,  even  if  present,  is  not  to  be 
relied  upon  as  a  help  to  diagnosis.  Again,  the  chest  in  a 
young  child  is  exceptionally  resonant,  and  it  is  not  always 
easy  to  detect  variations  in  its  sonority.  A  great  mistake, 
often  made  in  the  examination  of  children,  consists  in 
using  only  one  finger  as  a  percussor.  By  using  two 
fingers  we  can  equally  moderate  the  force  of  the  blow, 
while  at  the  same  time  we  elicit  a  far  greater  volume  of 
sound.  An  amount  of  dulness  which  escapes  the  ear, 
when  percussion  is  made  with  only  one  finger,  can  often  be 

18 


274  CHRONIC  PULMONARY  TUBERCULOSIS 

readily  brought  out  when  two  fingers  are  employed.  At 
the  apices  dulness  is  best  detected  in  infants  and  young 
children  at  the  supra- spinous  fossae,  and  can  often  be 
discovered  at  these  spots  when  in  front  the  percussion 
note  is  perfectly  healthy.  Great  care  must,  however, 
be  taken  to  exclude  all  sources  of  fallacy  in  estimating  the 
degree  of  resonance  of  the  apices.  One  shoulder  higher 
than  the  other,  or  a  cramped  position  bringing  the  mus- 
cles attached  to  the  shoulder  into  action,  will  produce  a 
dull  sound  on  percussion  which  is  not  due  to  the  con- 
dition of  the  lung.  In  infants,  in  examining  the  supra- 
spinous fossae,  it  is  advisable  to  place  the  child,  stripped 
to  the  waist,  on  the  nurse's  left  arm,  so  that  his  head  and 
right  arm  hang  over  her  left  shoulder,  the  left  arm  of  the 
child  being  round  his  nurse's  neck.  In  this  position  the 
muscles  of  both  sides  are  relaxed,  and  if  the  child  remain 
quiet  the  results  of  percussion  may  be  relied  upon.  Per- 
cussion should  be  made  upon  the  two  sides  at  the  same 
period  of  the  respiratory  movement.  Thus,  if  one  side 
has  been  percussed  during  inspiration,  it  will  be  necessary 
to  wait  until  another  breath  is  taken  before  subjecting 
the  opposite  side  to  the  same  test.  On  account  of  the 
readiness  with  which  false  conclusions  may  be  drawn 
with  regard  to  the  degree  of  resonance  of  the  lung  in 
children,  it  is  best  to  require  a  considerable  amount  of 
dulness  on  percussion  before  making  any  positive  infer- 
ence from  the  examination.  Slight  differences  between 
the  two  sides  should  be  allowed  little  weight,  for  a  spot 
which  ax3peared  to  be  dull  at  one  visit,  may  on  the  next 
seem  perfectly  healthy,  the  difference  probably  depending 
upon  various  degrees  of  expansion  of  the  lung  tissue  at 
that  spot. 

The  dulness,  although  often  situated  at  the  apex,  is  not 
necessarily  so.  The  whole  chest  should  be  carefully  per- 
cussed both  at  the  back  and  at  the  front.  Dulness  may 
be  found  in  spots  separated  by  tissue  which  yields  a 


AUSCULTATION 


275 


normal  resonance,  or  may  be  limited  to  an  area  in  the 
middle  of  the  lung  or  at  the  base.  In  fact,  wherever 
catarrhal  pneumonia  may  have  occurred  about  the  lung,  a 
deposit  may  be  left  to  impair  the  natural  resonance  at 
that  spot. 

Of  the  varieties  of  the  percussion  note  little  need  be 
said.  To  the  tubular  note  no  importance  can  be  attached  ; 
and  the  "cracked-pot"  sound  is  a  natural  phenomenon 
if  the  chest  be  percussed  during  expiration,  or  when  the 
mouth  is  open. 

In  practising  auscultation  we  must  remember  that 
coarseness  and  harshness  of  the  respiratory  murmur 
(puerile  breathing)  is  a  natural  condition  in  the  child, 
and  that  expiration  is  often  prolonged,  especially  at  the 
apices,  without  its  being  necessarily  a  sign  of  disease. 
Even  from  differences  in  respect  to  loudness  and  coarse- 
ness on  the  two  sides  we  cannot  prudently  draw  any 
positive  conclusion.  When,  however,  the  intch  of  the 
breath- sound  is  raised  on  one  side,  we  may  rely  upon  such 
a  change  as  evidence  of  disease,  and  may  expect  the  respi- 
ration to  become  distinctly  bronchial  in  the  course  of  a  few 
days. 

Even  when  the  breathing  at  a  particular  spot  is  bron- 
chial or  hollow,  we  have  still  to  satisfy  ourselves  that  the 
abnormal  quality  is  not  conducted  from  the  throat  or 
primary  divisions  of  the  air-tubes.  In  children  who  suffer 
from  enlarged  bronchial  glands  or  adenoid  growths,  and 
even  in  some  children  who  in  such  respects  show  no  sign 
of  disease,  sounds  from  the  large  bronchi  or  the  pharynx 
are  conducted  readily  to  the  chest,  and  loud  hollow 
breathing  may  be  heard  at  the  apices  of  perfectly  healthy 
lungs.  On  this  account  it  is  important  that,  if  possible, 
the  child's  mouth  be  open  during  the  examination,  as 
pharyngeal  sounds  are  then  less  easily  transmitted. 

On  account  of  this  ready  passage  of  extraneous  sounds 
to  the  chest,  the  use  of  the  stethoscope  is  imperative  to 


276  CHRONIC   PULMONARY  TUBERCULOSIS 

insure  accuracy  of  observation,  as  it  is  only  by  sucli  means 
that  we  can  limit  the  area  under  investigation  and  examine 
the  lungs,  so  to  speak,  bit  by  bit.  If  the  instrument  is 
spoken  of  as  a  ''trumpet,"  children  who  are  old  enough  to 
understand  the  term,  seldom  manifest  much  opposition  to 
its  use,  especially  if  they  are  allowed  to  touch  and  l-)lay 
with  it  beforehand  ;  and  infants  in  whom  the  chest  disease 
is  extensive  are  often  remarkably  quiet  during  examina- 
tion, being  usually  too  much  occupied  by  their  own  sen- 
sations to  make  any  resistance  to  the  operation.  Over 
the  seat  of  dulness  the  respiratory  murmur  is  either  weak 
and  suppressed,  or  is  bronchial,  blowing,  or  cavernous, 
with  increased  resonance  of  voice  and  cry.  As  the  tissue 
softens  and  breaks  up,  moist  crackles  are  heard  accom- 
panying the  breath- sounds,  or  there  is  merely  a  click  or 
two  at  the  end  of  inspiration.  This  passes,  as  cavities 
form,  into  gurgling,  or  large  bubbling  rhonchus,  more  or 
less  metallic. 

The  stethoscopic  signs  differ  in  value  according  to  the 
part  of  the  chest  at  which  they  are  heard.  At  the  apices 
mere  harshness  of  respiration  is  insignificant,  and  pro- 
longed expiration  absolutely  worthless  as  a  means  of  dia- 
gnosis. Bronchial  breathing  is  a  natural  condition  between 
the  scapulfB  over  the  site  of  the  principal  divisions  of  the 
air-tubes  ;  and  at  the  apices  may  be  closely  simulated  by 
sounds  conducted  from  the  naso-pharynx.  If  this  con- 
duction can  be  excluded,  bronchial  breathing  heard  at  the 
supra- spinous  fossae  is  often  the  sign  of  a  cavity.  In  the 
case,  however,  of  bronchial  blowing  and  cavernous  breath- 
ing, enlarged  bronchial  glands  in  contact  on  one  side. with 
the  air-tubes,  and  on  the  other  with  the  chest  wall,  may, 
by  their  conducting  power,  simulate  these  varieties  of  re- 
spiration so  closely,  that  from  a  single  examination  it  is 
often  impossible  to  give  a  positive  opinion  as  to  the  condi- 
tion of  the  lung.  It  is  only  by  a  careful  observation  of 
the  succession  of  these  sounds  that  a  conclusion  can  be 


VALUE   OF  CAVERNOUS  BREATHING 


277 


arrived  at.  In  the  case  of  pulmonary  consolidation  and 
excavation  the  breathing  becomes  more  and  more  distinctly 
metallic  and  cavernous,  while  (if  the  sounds  are  due  to 
conduction)  cavernous,  bronchial,  and  harsh  breathing  will 
be  found  to  alternate  irregularly  with  one  another.  Bron- 
chial respiration  is  therefore  more  significant  of  consoli- 
dation when  heard  at  the  base  of  the  lung  than  at  the  apex. 
The  same  may  be  said  of  feeble  breath- sounds  ;  although 
merely  weak  breathing  is  so  common  in  young  persons  at 
all  parts  of  the  chest,  from  insufficient  expansion  of  the 
lung,  that  at  a  first  examination  too  much  importance 
should  not  be  attached  to  it.  If  it  be  found  to  persist 
for  several  weeks,  or  if  it  occupy  the  whole  of  one  lung 
from  apex  to  base,  it  becomes  a  sign  of  considerable 
value. 

Cavernous  breathing  combined  with  dulness,  gurgling 
rhonchus,  and  increased  resonance  of  the  voice  and  cry, 
'usually  indicates  a  cavity  near  the  surface  of  the  lung. 
But  in  every  case  where  these  signs  are  met  with,  we  must 
not  hurry  to  the  conclusion  that  the  lung  tissue  is  exca- 
vated at  that  point.  At  the  apex  such  breathing  may  be 
simulated  closely,  as  we  know,  by  sounds  conducted  from 
the  pharynx ;  and  at  the  base  it  is  by  no  means  to  be 
accepted  in  every  case  as  a  sign  of  ulcerative  destruction 
of  lung.  Cavernous  respiration  heard  at  the  lower  lobe  of 
either  lung  is  more  commonly  the  consequence  of  bronchi- 
ectasis than  of  a  cavity  ;  but  it  may  be  also  detected  in 
cases  where  the  sole  pathological  lesion  present  is  a  copious 
pleuritic  effusion.  The  distinction  between  these  conditions 
will  be  considered  under  the  head  of  diagnosis. 

In  the  different  forms  of  pulmonary  consumption,  the 
course  of  the  physical  signs  is  often  fairly  expressive  of 
the  nature  of  the  disease. 

In  chronic  primary  tubercular  phthisis  signs  are  late  to 
appear,  and  at  first  may  easily  escape  notice.  Often,  indeed, 
the  slight  evidence  of  disease  obtained  by  a  physical  exa- 


278  CHRONIC  PULMONARY  TUBERCULOSIS 

mination  of  the  chest  in  a  case  where  the  severity  of  the 
general  symptoms  had  attracted  much  attention,  excites 
considerable  surprise.  A  child  who  is  described  as  having 
ailed  for  over  three  months,  with  hollow  cough,  evening 
fever,  and  loss  of  flesh  and  strength,  may  present  on  exa- 
mination merely  a  slight  want  of  resonance  at  the  apices 
of  the  lungs,  with  weak  harsh  breathing,  and  an  occasional 
click  in  inspiration,  changing  to  a  faint  dry  crackle  after  a 
cough.  In  this  variety,  although  one-half  of  the  chest  is 
first  attacked,  the  opposite  side  becomes  affected  after  a 
short  interval ;  and  usually  by  the  time  any  positive  phy- 
sical signs  are  present,  they  are  discovered  at  both  apices. 
In  most  cases  inflammation  is  soon  excited  in  the  part,  and 
a  secondary  catarrhal  pneumonia  is  set  up  which  produces 
marked  dulness  and  all  the  signs  of  consolidation.  When 
this  occurs,  the  existence  of  grey  tubercle  as  the  original 
factor  in  the  disease  may  be  overlooked  ;  although  the  pre- 
sence of  mischief  in  both  lungs,  and  the  severe  general 
symptoms,  combined  with  a  history  of  the  beginning  of 
the  attack,  should  make  the  nature  of  the  illness  a  matter 
of  the  strongest  suspicion. 

Sometimes  the  tubercular  disease  remains  uncomplicated 
with  pneumonia.  Disorganisation  then  goes  on  slowly : 
the  breath- sound,  although  still  feeble,  becomes  gradually 
blowing  in  quality,  and  eventually  all  the  signs  of  a  cavity 
are  discovered  at  one  apex.  It  is,  however,  rare  for  the 
inflammatory  element  to  be  absent.  Far  more  frequently 
the  disorganisation  of  the  lung  is  effected  through  the 
breaking  down  of  pneumonic  cheesy  matter.  The  signs  are 
then  much  more  marked,  and  are  consequently  more  easily 
recognisable. 

When  a  pneumonic  phthisis  begins  by  the  gradual  ex- 
tension of  a  bronchial  catarrh  to  the  alveoli,  the  earliest 
signs  are  discoverable  at  the  apex  of  the  lung.  There  is 
some  loss  of  resonance  on  percussion  ;  the  respiration  is 
high-pitched  or  faintly  bronchial,  and  a  click  or  dry  crackle 


SEAT  OF  THE  PHYSICAL  SIGNS 


279 


is  heard  at  the  end  of  a  deep  inspiration.  These  signs 
may  be  discovered  either  at  the  front  or  at  the  back  ;  per- 
haps it  is  most  common  to  meet  with  them  first  at  the 
supra- spinous  fossa.  Soon,  however,  they  begin  to  be 
noticed  also  above  the  clavicle.  Thenceforth,  unless 
measures  be  taken  to  counteract  the  evil,  the  progress  of 
the  disease  is  more  rapid,  and  it  is  not  long  before  evident 
signs  of  consolidation  are  found  at  the  apex  of  the  lung 
on  one  side  of  the  chest.  In  this  form  of  pulmonary 
phthisis  the  physical  signs  appear  early,  and  precede  any 
marked  symptoms  of  general  impairment  of  health.  Such 
cases  offer,  therefore,  a  remarkable  contrast  to  the  tuber- 
cular variety  of  the  disease  which  has  just  been  con- 
sidered. 

When  the  phthisis  results  from  an  unabsorbed  deposit 
left  after  an  attack  of  acute  catarrhal  inflammation,  or  is 
due  to  infection  by  a  caseous  bronchial  gland,  its  situation 
is  indicated  by  percussion-dulness,  and  all  the  usual  signs 
which  accompany  a  solidification  of  the  lung.  In  such 
cases  the  apex  is  not  necessarily  affected ;  indeed,  it  is  the 
exception  to  find  the  upper  third  of  the  lung  involved  in 
the  disease.  Far  more  commonly  the  signs  are  discovered 
at  the  base  or  in  the  middle  third;  and  therefore,  in  a 
physical  examination  of  the  chest,  every  part  should  be 
thoroughly  explored.  But  here  again  it  is  to  be  remarked, 
as  in  the  former  case,  that,  until  the  disease  is  far 
advanced,  the  physical  signs  often  indicate  a  greater 
amount  of  mischief  than  a  consideration  of  the  general 
symptoms  would  have  led  us  to  expect. 

When  softening  takes  place  in  the  caseous  mass,  wherever 
this  may  be  situated,  attention  should  at  once  be  directed 
to  the  apex  of  the  opposite  lung.  A  careful  examination 
will  probably  detect  a  rise  of  pitch  in  the  breath- sound  at 
this  point,  with  one  or  two  faint  clicks  in  inspiration,  and, 
possibly,  some  diminution  of  resonance  on  percussion.  As 
the  softening  process  advances,  these  signs  of  secondary 


280  CHRONIC  PULMONARY  TUBERCULOSIS 

lesion  become  more  and  more  manifest,  and  by  the  time  a 
cavity  has  become  established  at  the  original  seat  of 
disease,  the  apex  of  the  lung,  on  the  other  side  of  the 
chest,  usually  furnishes  distinct  evidence  of  consolida- 
tion. 

In  fibroid  induration  of  the  lung  the  physical  signs  are 
limited,  usually  throughout,  to  one  side,  and  may  be  found 
at  the  upper  part  of  the  chest  or  at  the  base.  In  an  early 
stage,  little  more  is  noticed  than  a  wooden  quality  of  per- 
cussion note,  with  slightly  increased  resistance,  and  harsh 
bronchial  breathing.  If  there  be  accompanying  catarrh, 
some  coarse  bubbling  or  crepitating  rhonchus  may  be 
caught  here  and  there  about  the  chest  and  back.  Yocal 
fremitus,  if  present  on  the  sound  side,  cannot  be  felt  over 
the  affected  part ;  but  the  resonance  of  the  voice  at  first  is 
normal. 

As  the  disease  proceeds,  the  lung  becomes  contracted; 
the  bronchi  dilate;  and  the  chest  falls  in.  On  account 
of  the  diminished  size  of  the  lung,  the  circumference  of 
the  side  is  reduced.  The  chest  is  flattened  at  the  seat  of 
disease,  and  the  heart  and  mediastinum  are  drawn  towards 
the  affected  part.  The  apex-beat  of  the  heart  is,  conse- 
quently, displaced,  and  the  resonance  of  the  opposite  lung- 
passes  across  the  middle  line  of  the  chest.  There  is  little 
respiratory  movement  over  the  indurated  lung,  and  vocal 
vibration  is  usually  completely  absent. 

The  percussion  note  is  wooden  or  tubular,  with,  in  many 
cases,  marked  sense  of  resistance.  The  respiratory  sounds 
vary  according  to  the  amount  of  secretion  contained  in 
the  tubes.  If  there  be  much  accumulation,  the  breathing 
is  weak  and  bronchial,  with  little  rhonchus,  and  but  faint 
resonance  of  the  voice.  If,  on  the  contrary,  the  dilated 
tubes  are  nearly  empty,  the  respiration  is  loud  and  caver- 
nous, with  much  clicking  rhonchus  mixed  up  with  creaking 
sounds,  and  vocal  resonance  is"  intense  and  bronchophonic. 
As  a  rule,  a.ttacks  of  catarrhal  pneumonia  are  frequent. 


FIBROID  INDURATION  OF  LUNG  281 

The  area  of  dulness  is  then  extended,  the  sense  of  resist- 
ance to  the  finger  becomes  extreme,  and  to  the  stethoscope 
the  breath- sounds  are  almost  obscured  by  profuse,  loud 
metallic  crepitation. 


CHAPTER  X 


CHRONIC  PULMONARY  TUBERCULOSIS  (continued) 

T\IAGNOSIS. — In  the  diagnosis  of  pulmonary  phthisis 
we  have  first  to  satisfy  ourselves  as  to  the  special 
variety  of  the  case  before  us,  and  then  to  determine  the 
stage  at  which  the  disease  has  arrived.  The  task  of 
classification  is,  however,  not  always  an  easy  one,  for  the 
types  of  disease  seldom  remain  separate  and  defined.  On 
the  contrary,  they  are  apt  to  run  into  one  another,  and 
blend  together,  so  as,  in  a  great  measure,  to  lose  their 
distinctive  characters. 

In  uncomplicated  chronic  primary  pulmonary  tuberculosis 
the  physical  signs  are  slight  at  the  first,  and  even  in  the 
child  usually  involve  the  apices  of  both  lungs.  In  a  well- 
marked  case  resonance  is  impaired;  there  is  bronchial 
breathing ;  and  at  the  end  of  deep  inspiration  a  faint 
crackle  is  heard,  which  becomes  louder,  and  more  dis- 
tinctly crepitating  after  a  cough.  These  signs  found  at 
the  apex  on  both  sides  of  the  chest,  and  continuing 
unchanged  for  several  weeks,  afford  the  strongest  suspicion 
of  the  presence  of  tubercle. 

In  many  cases  the  signs  are  much  less  clearly  defined, 
and  it  is  often  impossible  at  the  first,  or  even  after  several 
successive  examinations,  to  come  to  any  positive  conclusion 
as  to  the  exact  nature  of  the  illness.  To  arrive  at  a 
diagnosis,  we  must  take  into  account  the  family  history. 


DIAGNOSIS 


283 


the  special  history,  the  conformation  of  body,  and  the 
general  symptoms  of  the  disease.  Thus,  if  a  child  born  of 
consumptive  parents,  and  whose  general  build  corresponds 
to  the  type  which  has  been  described  as  significant  of  the 
tuberculous  diathesis,  becomes  languid,  and  mopes ;  if  he 
has  irregular  attacks  of  fever,  loses  flesh,  complains  of 
vague  pains  and  oppression  about  the  chest,  and  after  a 
time  begins  to  suffer  from  a  short  dry  cough,  we  should 
suspect  tubercular  phthisis.  If  these  symptoms  have 
succeeded  to  an  attack  of  measles  or  whooping-cough, 
our  suspicions  are  strengthened ;  but  so  long  as  percussion 
of  the  chest  shows  no  dulness,  and  auscultation  reveals 
nothing  but  harshness  of  respiration  at  the  upper  part  of 
the  lungs,  with  an  occasional  sibilant  or  sonorous  rhonchus 
here  and  there  about  the  chest,  we  should  still  hesitate  to 
give  a  decided  opinion.  When,  however,  resonance  at  both 
apices  becomes  impaired,  and  bronchial  breathing  is  heard 
with  a  faint,  dry  crackle  at  the  end  of  inspiration,  these 
signs,  taken  in  conjunction  with  the  suspicious  general 
symptoms,  can  leave  little  room  for  doubt. 

There  is  one  source  of  fallacy  which  it  is  important  to 
be  aware  of.  In  children,  especially  in  the  younger  sub- 
jects, who  suffer  from  mild  pulmonary  catarrh,  we  often 
find  little  patches  of  pulmonary  collapse.  These  patches 
are  especially  common  at  the  apices,  and  cause  slight  dul- 
ness of  percussion  at  the  supra-spinous  fossae.  If,  at  the 
same  time,  the  child  is  troubled  with  adenoid  vegetations 
in  the  naso-pharynx,  loud,  hollow  breath- sounds  conducted 
from  the  throat  are  heard  with  the  stethoscope  over  the 
dull  area.  The  likeness  to  pulmonary  phthisis  is  made 
more  close  by  the  anaemia  and  malnutrition  which  so  often 
accompany  the  post-nasal  growths;  but  the  distinction  is 
not  difficult.  The  mere  fact  that  adenoids  are  present 
should  excite  suspicion ;  and  when  we  find  that  the  hollow 
respiration  is  greatly  modified  while  the  child  holds  the 
mouth  open,  and  that  the  percussion  signs  vary  from  day 


284  CHRONIC  PULMONARY  TUBERCULOSIS 


to  day,  coming  and  going  capriciously,  we  may  exclude 
tuberculosis  of  the  lung  with  a  high  degree  of  certainty. 

In  cases  where  from  the  ill- defined  character  of  the 
physical  signs  we  had  been  obliged  to  reserve  an  opinion 
as  to  the  condition  of  the  apices,  the  occurrence  of  double 
pneumonia  at  these  spots  throws  considerable  light  ujDon 
the  difficulty,  and  greatly  increases  the  probability  that 
the  disease  is  tiibercular. 

At  a  later  stage,  when  the  tubercular  disease  has  become 
complicated,  and  secondary  catarrhal  pneumonia  has 
greatly  extended  the  limits  of  pulmonary  consolidation, 
it  would  be  difficult,  perhaps  impossible,  from  a  considera- 
tion merely  of  the  physical  signs  to  detect  at  first  sight  the 
tubercular  origin  of  the  disease.  If  the  apices  of  both 
lungs  are  unaffected,  the  mischief  is  probably  non-tuber- 
cular ;  but  if,  as  usually  happens  in  cases  of  pneumonic 
phthisis  when  pulmonary  disintegration  is  going  on,  both 
apices  are  involved,  we  cannot  solve  the  question  by  mere 
physical  examination.  In  such  a  case  an  accurate  account 
of  the  child's  illness  is  of  the  utmost  importance,  and  from 
the  history,  the  more  rapid  course  of  the  complaint,  and 
the  greater  severity  of  the  general  symptoms,  we  may 
often  be  justified  in  inferring  ihat  the  case  is  not  one  of 
lingering  broncho-pneumonia,  but  that  the  mischief  took 
its  origin  in  tubercular  formation  at  the  apices  of  the 
lungs. 

In  pneumonic  phthisis  we  can  often  succeed  in  dis- 
covering a  distinct  period  at  which  the  first  symptoms 
were  noticed.  A  child  delicate,  perhaps,  but  in  his  usual 
health,  is  seized  with  an  attack  of  vomiting,  followed  by 
fever,  cough,  and  general  chest  symptoms.  The  strength 
is  not  much  reduced,  and  the  breathing  is  but  little 
oppressed,  although  it  may  be  rather  more  hurried  than 
natural. 

If  the  child  be  seen  eaily,  no  dulness  may  be  found  on 
percussion,  but  there  is  more  or  less  coarse  crepitation 


SECONDARY  TUBEK-CULAR  PHTHISIS  285 

heard  at  one  or  more  spots  about  tlie  chest,  often,  how- 
ever, at  the  apex  of  one  lung — seldom  at  both  if  the 
disease  be  uncomplicated.  The  crepitation  accompanies 
the  expiration  as  well  as  the  inspiration,  and  varies  greatl}- 
in  amount  from  day  to  day ;  sometimes  more  being  heard, 
sometimes  less,  and  sometimes  for  a  short  time  it  is  com- 
pletely absent.  If  any  dulness  be  present,  it  is  slight  at 
first,  and  may  not  become  more  marked  for  several  weeks. 
The  breath-sounds  are  not  necessarily  altered  in  character. 
The  temperature  of  the  body  rises  at  night  to  102°  or  103° 
Fahr.,  falling  in  the  morning  to  about  its  natural  level. 

After  a  time,  often  only  after  several  weeks,  the  dulness 
becomes  more  marked,  and  then  gradually  increases  in 
intensity  and  extent ;  the  respiration  is  bronchial  or  tubu- 
lar ;  and  the  coarse  crepitation,  persisting,  is  heard  over 
the  whole  of  the  consolidated  part,  but  varies  in  amount 
as  before,  and  occasionally  is  replaced  for  a  time  by  a 
rhonchus  of  larger  size. 

An  attack  of  subacute  catarrhal  pneumonia,  such  as  the 
above,  running  a  tedious  course,  and  leaving  behind  it  an 
unabsorbed  consolidation,  may  undergo  complete  resolution 
after  a  time,  and,  indeed,  is  often  seen  to  do  so.  But  often, 
too,  tubercle  bacilli  find  their  way  to  the  affected  part,  and 
the  solidifying  material  begins  to  soften  and  disintegrate ; 
or  the  part  becomes  thickened  with  new  fibroid  tissue,  and 
permeated  with  dilated  bronchi.  Disease  thus  induced 
may  affect  any  part  of  the  lung,  but  is  usually  confined  to 
one  side  of  the  chest — at  any  rate,  at  first. 

Tubercular  disease  spreading  from  a  caseous  gland  at 
the  root  of  one  lung  often  announces  itself  by  the  physical 
signs  of  a  localised  broncho-pneumonia.  The  signs,  how- 
ever, in  such  a  case  are  not  found  at  the  apex,  but  are 
seated  lower  down  in  the  lung,  often  at  the  upper  border 
of  one  of  the  lower  lobes,  and  are  first  discovered  about 
the  middle  of  the  scapular  region  on  one  side. 

Pneumonic  phthisis,  like  the  primary  form,  may  have 


286  CHRONIC  PULMONARY  TUBERCULOSIS 

a  very  insidious  beginning.  In  cases  where  a  pulmonary 
catarrh,  spreads  gradually  from  the  larger  to  the  smaller 
air- tubes,  and  from  these  to  the  alveoli,  the  main  features 
of  the  disease  present  a  strong  similarity  to  those  present 
at  the  beginning  of  chronic  tubercular  phthisis ;  and  it  is 
necessary  to  make  very  minute  inquiries  to  establish  the 
difference.  One  of  the  chief  points  of  distinction  lies  in 
the  influence  of  the  illness  upon  nutrition.  In  primary 
tubercular  phthisis  the  general  symptoms  precede  the 
special.  Wasting  and  fever  are  present  from  the  begin- 
ning. The  child  loses  weight  rapidly,  and  his  haggard 
appearance  attracts  attention.  It  is  only  after  a  very 
distinct  interval  tha,t  he  is  noticed  to  cough.  In  chronic 
catarrhal  pneumonia  exactly  the  opposite  conditions  pre- 
vail. The  special  symptoms  are  the  first  to  appear.  Cough 
and  shortness  of  breath  are  remarked  upon  before  any  loss 
of  flesh  has  excited  observation,  and  although  the  tempera- 
ture is  higher  than  natural,  weeks  often  pass  before  any 
material  impairment  takes  place  in  the  nutrition  of  the 
child. 

Physical  signs,  when  present  at  the  apices  in  primary 
tubercular  disease,  are  met  with  on  both  sides  •  but  the 
comparatively  trifling  amount  of  structural  change  dis- 
covered by  physical  examination  presents  a  remarkable 
contrast  to  the  severe  disturbance  in  the  general  condition, 
and  forms  an  important  element  in  the  diagnosis.  In 
pneumonic  phthisis,  on  the  contrary,  the  disease  is  at  first 
confined  to  one  side  of  the  chest,  and  often  proves  on  exa- 
mination to  be  far  more  extensive  than  the  well-nourished 
state  of  the  patient  had  led  us  to  anticipate. 

Advanced  pneumonic  phthisis  is  often  complicated  with 
general  disseminated  tuberculosis.  We  may  suspect  this 
if  we  find  great  hurry  of  breathing,  with  an  increase  in  the 
pyrexia,  without  any  extension  of  the  physical  signs. 
There  is  usually  also  considerable  irritability  of  the  diges- 
tive organs  with  vomiting  or  diarrhcea.    If  in  such  a  case 


FIBROID  INDURATION   OF  LUNG 


287 


conyulsions  occur  with  squinting,  inequality  of  pupils,  and 
other  signs  of  intra-cranial  disease,  our  suspicions  are 
amply  confirmed. 

In  fibroid  induration  or  cirrhosis  the  disease  is  limited 
to  one  lung.  The  affected  side  is  retracted,  often  con- 
siderably ;  the  front  of  the  chest  is  flattened,  the  respira- 
tory movement  slight,  and  the  heart  more  or  less  displaced. 
If  the  disease  occupies  the  left  side,  the  heart  is  drawn  up- 
wards ;  if  the  right  side,  the  heart  is  drawn  towards  the 
middle  line.  Real  elevation  of  the  heart  must  not  be  con- 
founded with  apparent  elevation  through  unnatural  obli- 
quity of  the  ribs  occurring  in  long-chested  children.  There 
is  dulness  on  percussion  over  the  seat  of  disease — usually 
the  middle  third  of  the  lung  approaching  more  or  less  to 
the  apex.  The  note  is  often  tubular,  and  there  is  unusual 
parietal  resistance.  Auscultation  shows  harsh,  bronchial, 
or  blowing  respiration,  with  coarse  rhonchus  and  increa.sed 
resonance  of  voice,  passing,  as  the  bronchi  dilate,  into 
cavernous  respiration,  with  gurgling  and  pectoriloquy.  A 
systolic  basic  murmur  is  sometimes  present,  produced 
probably  by  pressure.  There  is  no  febrile  disturbance  ;  on 
the  contrary,  the  temperature  is  unusually  low. 

In  extensive  consolidation  of  the  upper  part  of  one  side 
only,  the  other  side  giving  no — not  even  the  faintest — 
sign  of  disease,  the  diagnosis  lies  between  pneumonic 
phthisis  and  fibroid  induration.  The  existence  of  retrac- 
tion of  the  affected  side,  the  altered  position  of  the  heart, 
the  flatness  of  the  percussion-note,  the  great  resistance, 
and  the  absence  of  fever,  exclude  the  former  disease.  It 
is  distinguished  from  chronic  pleurisy  with  retraction 
by  the  resonance  at  the  base,  and  by  the  signs  of  a  cavity. 

It  is  not  always  easy  to  satisfy  ourselves  as  to  the  exist- 
ence of  a  cavity  in  the  lung,  for,  although  present,  it  may 
give  rise  to  no  very  positive  signs ;  and  again,  although 
absent,  the  physical  signs  usually  indicative  of  excavation 
may  be  present. 


288 


CHRONIC  PULMONARY  TUBERCULOSIS 


In  infants,  and  children  of  three  or  four  years  old, 
the  signs  of  a  cavity  are  often  very  obscure,  consisting 
merely  in  bronchial  breathing  with  fine  bubbling  rhonchus 
and  bronchophony.  Here  no  positive  opinion  should  be 
hazarded.  It  must  be  remembered,  however,  that  at 
such  an  age  ulceration  of  the  lung  is  not  a  common 
condition. 

In  the  case  of  older  children,  a  dull,  tubular,  or  tym- 
panitic percussion-note,  with  gurgling  and  bronchophonic 
resonance  of  the  voice — signs  usually  indicative  of  a 
cavity — may  be  produced  by  dilated  bronchi,  and  are 
occasionally  very  closely   simulated  in   some  cases  of 
pleuritic  effusion.    Empyema,  indeed,  is  frequently  mis- 
taken for  pulmonary  phthisis,  and  the  error  is  one  which 
may  be  easily  made.    In  many  cases  of  empyema  there  is 
hectic  fever,  with  wasting  and  great  weakness ;  there  is 
failure  of  appetite,  irritability  of  the  digestive  organs, 
cough  and  shortness  of  breath.    An  examination  of  the 
chest  shows  extensive  dulness,  with  blowing  or  cavernous 
breathing,  and,  often,  a  crepitating  friction- sound  which 
may  bear  a  near  resemblance  to  rhonchus  in  the  lung.  In 
cases  such  as  these  we  can  scarcely  be  surprised  if  the 
patient  is  supposed  to  be  consumptive.    But  a  little  reflec- 
tion should  alter  this  oj^inion,  and  make  us  reconsider  our 
diagnosis.    The  fact  that  disease  in  an  apparently  advanced 
stage  is  limited  strictly  to  one  side  of  the  chest,  should 
always  excite  our  suspicions.    If,  then,  we  refer  to  the 
history  of  the  complaint,  and  find  that  the  illness  began 
suddenly  with  pain  in  the  side,  followed,  after  a  day  or  two, 
by  cough ;  if  we  note  the  character  of  the  physical  signs, 
and  remark  that  the  dulness  is  comj^lete  with  great  sense 
of  resistance ;  that  it  is  found  both  at  the  front  of  the 
chest  and  at  the  back  ;  and  that  however  high  it  may  reach 
upwards,  it  persists  even  to  the  extreme  base  below — we 
cannot  but  conclude  that  these  features  in  the  cases  are  not 
reconcilable  with  what  we  know  of  pulmonary  consumption, 


DIAGNOSIS  OF  A  CAVITY 


289 


but  must  be  referred  to  some  other  cause ;  and  this  cause 
there  can  be  no  doubt  is  pleurisy. 

Whether  the  cavernous  signs  be  due  to  a  dilated  bron- 
chus or  an  excavation  in  the  lung,  it  is  not  always  easy  to 
determine ;  but  with  regard  to  the  ultimate  issue  of  the 
case  it  is  of  the  highest  importance  to  make  the  distinction. 
A  child  after  an  attack  of  catarrhal  pneumonia  recovers 
flesh  slowly,  and  remains  feeble  with  slight  fever  at  night. 
An  examination  of  the  chest  detects  dulness  and  cavernous 
respiration  with  large  metallic  bubbling  rhonchus  and 
bronchophony  at  the  lower  part  of  one  lung.  Here  it  is  of 
the  greatest  moment  to  determine  whether  such  signs  are 
a  consequence  of  a  dilated  bronchus,  with  surrounding 
consolidated  tissue,  or  of  an  excavation  in  the  lung.  In 
the  one  case  the  child  may  be  expected  to  recover  com- 
pletely;  in  the  other  a  return  to  health  can  scarcely  be 
anticipated. 

If  the  signs  are  heard  at  the  base,  the  probabilities  are 
strongly  in  favour  of  bronchiectasis,  especially  if  the  apex 
of  the  lung  is  free  from  disease.  If  the  area  over  which 
the  abnormal  signs  prevail  gradually  increases  in  extent, 
our  suspicions  point  to  a  cavity,  for  dilated  bronchi 
usually  remain  unaltered,  or  tend  to  contract  and  become 
normal.  Yery  valuable  information  is  a:fforded  by  the 
general  symptoms.  If  the  patient  improves,  regains  flesh 
and  strength,  with  a  good  appetite  and  a  normal  or  only 
slightly  elevated  temperature,  we  may  reasonably  conclude 
that  no  lung  disintegration  is  going  on.  In  all  cases  a 
careful  examination  of  the  sputum  should  be  made  with 
the  microscope,  if  any  expectoration  can  be  obtained,  to 
search  for  fragments  of  elastic  tissue.  Such  fragments,  if 
areolar,  are  conclusive  evidence  of  ulcerative  excavation. 
It  is  necessary,  however,  to  make  many  examinations  of 
the  sputum  before  deciding  against  the  presence  of  the 
elastic  tissue. 

*  The  search  for  elastic  tissue  is  made  a  very  simple  process  by 

19 


290  CHRONIC  PULMONARY  TUBERCULOSIS 

It  is  of  course  quite  possible  that  the  two  conditions 
may  be  combined  in  the  same  lung,  as  we  see  in  cases  of 
fibroid  phthisis  where  ulceration  has  started  from  the 
wall  of  the  dilated  tube.  In  such  cases  we  get  the  local 
signs  of  bronchiectasis  combined  with  the  general  sym- 
ptoms of  pulmonary  excavation.  Thus,  if  the  cavernous 
signs  are  heard  at  the  middle  or  lower  part  of  one  lung 
the  apex  of  which  is  free  from  disease ;  if  there  be  con- 
siderable retraction  of  that  side  with  displacement  of  the 
heart;  and  at  the  same  time  if,  without  any  signs  of 
secondary  catarrhal  pneumonia,  we  find  a  high  tempera- 
ture and  general  constitutional  disturbance,  the  diagnosis 
of  fibroid  phthisis  may  be  made  without  hesitation. 

The  occurrence  of  ulceration  is  usually  followed  very 
quickly  by  secondary  deposits  in  the  apex  of  the  opposite 
lung.  Therefore,  if  in  a  case  of  fibroid  induration  we  find 
any  indication  of  disease  in  the  apex  on  the  other  side  of 
the  chest,  we  should,  from  this  sign  alone,  suspect  the 
presence  of  ulceration. 

Prognosis. — A  consolidation  of  the  lung,  left  after  an 
attack  of  broncho-pneumonia,  may  remain  for  a  long  time 
unabsorbed;  but  these  cases  are  not  cases  of  pulmonary 
phthisis,  and  may  be  expected  to  end  in  recovery.  If  the 
patient  be  placed  in  good  sanitary  conditions,  so  that 
special  infection  by  the  bacillus  can  be  prevented,  reabsorp- 
tion  takes  place  and  the  mischief  is  quickly  removed.  As 
sputum  is  rarely  brought  up  by  a  child,  and  we  are  usually 
deprived  of  the  aid  which  an  examination  of  expectorated 
matters  would  afford,  we  can  seldom  venture  on  a  first 
visit  definitely  to  exclude  tuberculosis.  A  fair  state  of 
nutrition  and  good  animal  spirits  on  the  part  of  the 
patient  may  enable  us  to  take  a  favourable  view  of  his 

boiling  the  sputum  in  a  test-tube  with  an  equal  quantity  of  liquor 
sodjB.  The  mixture  becomes  perfectly  clear,  and  fragments  of  elastic 
tissue,  if  present,  sink  to  the  bottom  of  the  tube,  whence  they  can  be 
readily  removed  by  a  pipette. 


PROGNOSIS 


291 


prospects ;  but  it  is  not  until  a  change  for  the  better  in 
the  child's  surroundings  is  followed  by  immediate  im- 
provement, and  the  consolidation  begins  at  once  to  be 
reabsorbed,  that  we  can  venture  to  dissipate  the  fears  of 
the  friends. 

When  definitely  established,  pulmonary  phthisis  is 
generally  fatal  sooner  or  later,  but  the  prognosis  is  always 
most  serious  in  cases  where  there  is  a  strong  family 
tendency  to  the  disease.  Such  cases  are  prone  to  go 
from  bad  to  worse  ;  general  nutrition  suffers  early  and 
severely ;  and  the  danger  of  the  disease  becoming  dis- 
seminated and  setting  up  an  acute  general  tuberculosis  is 
really  urgent. 

In  an  ordinary  case  of  pulmonary  phthisis  the  course  of 
the  illness  is  very  variable,  with  turns  of  improvement  and 
relapse.  G-reat  caution  should  then  be  exercised  in  making 
a  prognosis,  for  a  child  who  is  apparently  in  the  greatest 
danger  may  suddenly  begin  to  improve,  and  his  more 
serious  symptoms  may  for  the  time  completely  disappear. 
Such  amendment  is  apt  to  excite  amongst  his  friends 
hopes,  seldom  destined  to  be  realised,  of  a  complete 
recovery. 

This  improvement  often  happens  in  cases  where  the 
local  symptoms  are  temporarily  aggravated  by  a  bronchitic 
attack,  but  it  may  also  occur  in  cases  of  apparently  un- 
complicated local  tuberculosis.  When,  however,  the  chronic 
disease  is  once  fairly  established,  the  apparent  improve- 
ment is  almost  always  speedily  followed  by  a  relapse,  all 
the  symptoms  returning  with  increased  severity.  It  is  not 
often  possible  to  obtain  sputum  for  examination,  for 
many  children  cannot  be  persuaded  to  expectorate  the 
purulent  matter  brought  up  from  the  lung.  If  sputum 
can  be  obtained,  the  number  and  arrangement  of  the 
bacilli  are  said  by  some  observers  to  be  a  measure  of  the 
rapidity  with  which  the  disease  is  progressing ;  for  in 
cases  where  the  destructive  process  is  rapid  the  bacilli  are 


292  CHRONIC  PULMONARY  TUBERCULOSIS 

numerous,  and  are  arranged  in  groups  and  masses.  This 
rule,  however,  is  not  invariable.  In  cases  of  rapid  phthisis 
I  have  known  the  bacilli  in  the  expectorated  muco-pus  to 
be  very  few  in  number. 

Pulmonary  phthisis  often  lasts  much  longer  than  would 
be  expected  from  the  character  of  the  physical  signs.  A 
child  may  continue  in  the  same  state,  without  much 
improvement  or  aggravation  of  his  symptoms  for  years. 
It  becomes,  then,  a  question  of  much  importance  to  decide 
in  any  given  case  upon  the  prospects  of  a  lengthened 
course. 

The  most  favourable  conditions  are  those  where  a  child 
without  any  hereditary  tendency  to  the  disease  becomes 
infected  secondarily  with  the  bacillus  at  the  end  of  a 
lingering  attack  of  broncho-pneumonia.  This  pneumonic 
form  of  phthisis  when  it  attacks  a  constitutionally  healthy 
child  often,  I  think,  ends  in  recovery  if  the  consolidated 
area  be  limited  in  extent,  and  the  patient  live  a  healthy 
open-air  life.  In  such  a  case  the  progress  of  nutrition 
must  be  watched  with  care.  Absence  of  wasting  and  the 
occurrence  of  local  contractions  of  the  chest  wall  from  the 
formation  of  fibrous  tissue  at  the  affected  spot  are  sym- 
ptoms which  should  be  noted  with  satisfaction.  Even 
when  it  ends  unfavourably,  which  in  the  poorer  classes  of 
the  people  it  usually  does,  this  variety  of  the  disease  is 
often  very  sluggish  in  its  progress.  It  is,  however,  always 
liable  to  take  on  suddenly  a  more  rapid  course,  and  too 
great  confidence  should  not  be  excited  by  the  apparent 
inactivity  of  the  disease. 

Fibroid  induration  is  a  still  slower  disease.  In  such 
cases  the  immediate  outlook  is  far  from  being  unfavour- 
able. 

In  the  case  of  primary  tuberculosis  of  the  lung  very 
little  hope  can  be  given.  The  most  favourable  change 
appears  to  be  its  complication  with  cirrhosis  ;  by  this  means 
life  is  often  prolonged  for  a  considerable  time.  The 


PREVENTION 


293 


presence  of  tubercular  lesions  in  other  organs,  especially 
the  bowels,  is  very  unfavourable.  Diarrhoea  is  not  unfre- 
quently  the  direct  cause  of  death. 

Death  may  take  place  suddenly,  without  being  jjreceded 
by  any  great  aggravation  of  the  other  symptoms. 
Usually,  however,  it  is  ushered  in  by  greater  severity  of 
the  cough,  sensation  of  oppression  about  the  chest, 
lividity  of  the  face,  increased  weakness,  and  all  the  signs 
of  exhaustion.  Pneumothorax  is  very  rare  in  children. 
When  a  tuberculosis  becomes  generalised,  death  is  often 
preceded  by  the  symptoms  of  the  third  stage  of  tubercular 
meningitis. 

Prevention. — If  the  mother  be  consumptive,  she  should 
on  no  account  be  allowed  to  suckle  her  child  longer  than 
the  end  of  the  first  month;  a  healthy  wet-nurse  should 
then  be  provided  to  take  her  place.  So  much  has  been 
said  in  the  present  volume  as  to  the  feeding  and  general 
management  of  young  children  that  it  will  be  unnecessary 
to  repeat  in  this  place  the  various  rules  for  the  diet, 
clothing,  &c.,  of  infants,  which  have  been  already  laid 
down.  The  reader  is  referred  to  the  chapter  containing 
the  treatment  of  simple  atrophy,  and  to  that  on  the  pre- 
vention of  diarrhoea,  for  full  information  upon  these 
points. 

The  diet  of  an  older  child  should  be  so  arranged  that 
he  may  take  as  much  as  he  can  readily  digest,  but  no 
more.  Animal  food  should  be  given  to  him  only  once  in 
the  day,  and  should  be  either  roasted  or  boiled;  meat 
cooked  a  second  time,  as  hashes,  or  stews,  or  meat  fiied 
in  grease,  are  less  digestible,  and  should  not  be  allowed. 
After  the  age  of  two  years  a  child  should  take  four  meals 
a  day  :  of  these  two  should  consist  of  bread  and  milk  ; 
a  third  of  meat,  finely  minced  at  the  first,  afterwards  cut 
into  small  pieces,  with  a  little  potato  carefully  mashed, 
and  gravy;  a  fourth  of  farinaceous  pudding,  or  an  egg 
slightly  boiled.    The  milk  should,  if  possible,  be  fresh 


294  CHRONIC  PULMONARY  TUBERCULOSIS 


from  the  cow ;  if  not,  a  tablespoonful  of  cream  should  be 
added.  It  is  important  to  accustom  the  child  early  to 
masticate  his  food  thoroughly :  this  point  should  be  always 
attended  to.  Children  often  wake  hungry  in  the  early 
morning;  it  is  well  in  such  cases  to  place,  overnight,  a 
piece  of  dry  stale  bread,  or  a  plain  biscuit,  by  the  side  of 
their  bed,  so  that  they  may  not  be  forced  to  wait  without 
food  until  their  breakfast  is  prepared. 

Well- ventilated  rooms,  fresh  air,  and  plenty  of  exercise 
must,  of  course,  be  insisted  upon.  The  skin  should  be 
kept  perfectly  clean  by  cold  or  tepid  sponging  over  the 
whole  body  in  a  bath  once  a  day,  and  should  be  after- 
wards excited  gently  to  act  by  friction  with  hand. 

The  dress  should  be  warm  but  loose :  tight  waistbands, 
and,  in  girls,  stays  are  exceedingly  injurious.  Nothing 
should  be  allowed  to  interfere  with  the  free  play  of  the 
chest.  Pressure  upon  the  ribs  not  only  prevents  a  proper 
expansion  of  the  lungs,  but  also  is  apt  to  cause  displace- 
ment of  the  liver  and  stomach,  and  much  derangement 
of  the  functions  of  digestion  and  respiration  may  be  the 
consequence.  The  only  way,"  says  Dr.  Underwood, 
"  in  which  we  can  assist  in  forming  a  really  fine  figure,  is 
to  remove  all  restraint,  and  secure,  as  far  as  possible,  so 
free  an  action  to  the  muscles  as  will  lead  to  their  perfect 
development.  By  such  a  course  we  shall  best  promote 
the  acquirement  of  a  good  carriage,  which  is  infinitely 
more  likely  to  be  the  result  of  a  perfect  balance  of  the 
muscles  than  of  any  mechanical  support  whatever." 

The  j)receding  remarks  do  not  refer  to  the  abdominal 
belt,  which  should  always  be  worn  until  the  child  is,  at 
any  rate,  three  years  old.  The  band  covers  the  belly,  but 
does  not  confine  the  ribs,  if  properly  applied  round  the 
upper  part  of  the  pelvis. 

Children,  both  boys  and  girls,  should  be  encouraged  to 
exercise  their  muscles  by  outdoor  games,  and  by  gymnas- 
tic exercises  suited  to  their  age  and  sex.    While,  however, 


EARLY  REMOVAL  OF  DISEASED  BONE  295 

plenty  of  fresh  air  and  exercise  out  of  doors  are  of  extreme 
importance,  unnecessary  exposure  of  children  to  cold 
winds  and  damp  air,  with  a  view  of  hardening  the 
system,''  is  a  practice  which  cannot  be  too  strongly  con- 
demned. The  most  robust  children  are  exceedingly  sensi- 
tive to  changes  of  temperature,  and  in  cold,  damp  air 
readily  part  with  their  heat  and  become  pinched  and 
blue,  showing  that  they  are  suffering  from  the  effects  of 
cold.  Many  an  attack  of  inflammation  of  the  lungs  has 
been  excited  by  such  a  practice,  and  in  children  already 
predisposed  to  phthisis  unnecessary  exposure  is  one  of 
the  most  certain  ways  of  encouraging  the  tendency.  A 
dry,  airy  situation  should  be  always  recommended.  Dr. 
Buchanan  has  shown  that  phthisis  is  much  more  preva- 
lent amongst  populations  living  on  low-lying,  impervious 
soils  than  amongst  the  residents  of  places  more  highly 
situated  and  where  the  soil  is  pervious.  In  the  selection 
of  a  house  this  is  a  matter,  therefore,  of  much  importance. 

In  children  who  suffer  from  caries,  an  operation  for  the 
removal  of  the  diseased  portion  of  bone  should  not  be 
delayed.  Pulmonary  tuberculosis  may  be  set  up  by  bacilli 
transported  from  the  affected  bone,  as  has  already  been 
explained  (see  page  262).  When  the  bone  disease  is 
cured,  the  child  often  becomes  strong  and  healthy.  Early 
attention  must  also  be  paid  to  the  local  inflammations  and 
suppurations  to  which  scrofulous  children  are  so  liable. 
Pent-up  pus — whether  collected  in  abscesses  or  filling  the 
pleura  as  in  empyema — should  be  evacuated  without  loss 
of  time ;  and  tuberculous  glands  in  the  neck  must  be 
carefully  watched  and  removed  at  once  on  any  sign  of 
softening.  The  child  must  be  kept  scrupulously  clean, 
and  any  discharges  from  the  ears,  nose,  or  vagina  should 
be  at  once  treated  by  suitable  applications. 

In  cases  where  the  shape  of  the  chest  is  elongated  and 
narrowed  from  before  backwards,  showing  the  small  size 
of  the  lungs,  every  means  must  be  taken,  by  exercises 


296  CHKONIC  PULMONARY  TUBERCULOSIS 

carefully  proportioned  to  the  strength  of  the  patient,  to 
increase  the  capacity  of  the  chest  and  invigorate  the 
muscles  of  respiration.  This  is  effected  in  a  great 
measure  by  general  exercise ;  but,  besides  this,  the  more 
special  exercises,  as  the  use  of  the  dumb-bells  and  of  the 

chest-expander,"  are  particularly  valuable.  Drilling, 
fencing,  and  other  amusements  which  promote  the  acquire- 
ment of  a  good  carriage,  accustoming  the  child  to  throw 
back  the  shoulders  and  expand  the  lungs,  are  also  of  much 
service.  By  such  means  the  capacity  of  the  chest  may  be 
very  much  increased,  and  greater  freedom  be  given  to  the 
play  of  the  lungs. 

Treatment. — In  the  treatment  of  pulmonary  phthisis 
three  things  are  indispensable:  a  free  supply  of  fresh 
air,  avoiding  chills ;  a  moderate  amount  of  exercise, 
avoiding  over-fatigue ;  and  plenty  of  nourishing  food, 
avoiding  repletion  and  indigestion.  The  child  should 
pass  as  much  time  as  possible  out  of  doors  during  the 
day,  returning,  however,  to  the  house  before  sunset;  as 
the  temperature  often  falls  considerably  at  that  time,  and 
rapid  changes  of  temperature  are  to  be  avoided.  Cold  is 
not  so  injurious  as  damp.  These  patients,  if  warmly 
clothed,  often  bear  well  and  are  benefited  by  cold  air- 
Damp,  however — at  any  rate  the  moist  air  of  low-lying 
inland  situations — is  extremely  prejudicial,  and  while  the 
ground  is  wet  the  children  should  be  kept  indoors,  or 
should  only  be  exercised  with  very  great  caution.  The 
moist  air  of  the  sea- side  does  not  appear  to  be  so  injuri- 
ous, and  many  cases  of  pulmonary  phthisis  are  greatly 
benefi.ted  by  a  residence  near  the  sea.  For  the  winter 
months,  and  in  cases  where  a  change  of  air  is  advisable, 
it  often  becomes  a  question  of  considerable  difficulty  to 
decide  upon  the  best  climate  to  which  the  patient  can  be 
sent.  In  the  early  stage,  before  softening  has  begun  in 
the  lung,  it  may  be  laid  down  as  a  rule,  that  the  best 
climate  is  one  where  the  temperature  is  as  low  as  can  be 


CHOICE  OF  CLIMATE 


297 


borne.  A  warm  climate,  unless  in  exceptional  cases,  has 
no  special  advantage,  and  heat  combined  with  moisture, 
as  in  Ceylon  and  Madeira,  is  as  a  rule  positively  inju- 
rious. A  hot,  moist  climate  is  only  of  value  in  cases  where 
there  is  excessive  irritability  of  the  bronchial  mucous 
membrane,  a  condition  which  would  be  increased  by  warm 
dry  air.  In  the  earlier  stages  of  tuberculosis  this  is, 
however,  seldom  a  prominent  symptom.  The  object  of  a 
change  of  residence  in  this  disease  is  to  obtain  a  climate 
where  the  patient  can  pass  his  time  out  of  doors  without 
incurring  the  risk  of  catarrh,  and  where,  at  the  same 
time,  the  quality  of  the  air  is  sufficiently  invigorating. 
When  the  climate  is  damp  as  well  as  warm,  the  relaxing 
qualities  imparted  by  the  moisture  usually  cause  so  much 
depression,  destroying  the  appetite  and  increasing  the 
languor,  as  to  counteract  the  benefit  aiforded  by  the  more 
genial  air.  In  determining  this  question  regard  should 
always  be  paid  to  individual  peculiarities.  Some  children 
will  require  a  much  greater  degree  of  warmth  than 
others,  and  it  will  be  necessary  to  take  into  considera- 
tion the  influence  which  differences  in  temperature  have 
already  appeared  to  exercise  upon  the  health  of  the 
patient — whether  he  has  seemed  to  be  more  benefited  by 
heat  or  by  cold — before  deciding  in  any  case  upon  the 
exact  climate  which  offers  the  best  chance  of  recovery ^ 
For  the  special  advantages  afforded  by  different  localities 
the  reader  is  referred  to  the  many  excellent  works  upon 
this  subject  which  have  been  published.  It  may  be  re- 
marked, however,  that  dryness  of  soil  and  protection  from 
north  and  east  winds,  during  the  winter  and  early  spring, 
are  always  essential.  The  other  conditions  to  be  desired 
must  be  determined  by  the  requirements  of  the  particular 
case. 

In  the  later  stages  of  the  disease,  when  softening  of 
the  consolidating  matter  has  taken  place,  and  cavities 
have  formed,  a  warmer  climate  is  desirable;  but  even 


298  CHRONIC  PULMONARY  TUBERCULOSIS 

in  these  cases  there  are  great  differences  in  different 
patients,  and  some  will  require  a  much  less  degree  of 
heat  than  others.  Unless  there  be  great  irritability  of 
the  bronchial  mucous  membrane,  dryness  of  the  air  is  of 
extreme  importance,  as  a  dry  air,  although  warm,  still 
possesses  bracing  properties.  If  the  lungs  are  very 
irritable,  a  certain  amount  of  moisture  is  of  service ;  and 
many  places,  both  in  England  and  abroad,  are  recom- 
mended for  such  cases.  If,  however,  a  suitable  climate 
can  be  found  in  their  own  country,  it  is  well  not  to 
send  these  patients  too  far  from  home.  Invalids  feel 
acutely  the  absence  of  home  comforts,  and  in  the  last 
stage  of  the  disease  especially,  when  little  good  can  be 
hoped  for  from  travel,  it  is  cruel  to  send  them  away  merely 
to  die. 

Moderate  exercise  while  out  of  doors  should  always  be 
enjoined,  due  regard  being  had  to  the  degree  of  vigour  of 
the  patient.  This  is  of  great  importance,  for,  unless  the 
weather  be  warm,  a  proper  action  of  the  muscles  is  re- 
quired to  stimulate  the  circulation  and  prevent  the  body 
being  affected  by  the  cold.  Over-fatigue  must,  however, 
be  carefully  avoided ;  and  if  there  be  any  feeling  of  cold 
after  a  short  stay  in  the  open  air,  it  will  be  necessary  to 
return  at  once  to  the  house.  If  the  child  be  strong 
enough,  pony  or  donkey  exercise  may  be  recommended. 
In  cases,  however,  where  the  exertion  required  for  riding 
is  too  severe,  an  open  carriage  can  be  substituted;  and 
the  child  can  occasionally  take  a  short  walk,  returning  to 
the  carriage  when  fatigued.  Care  must  be  taken  that 
the  child  is  perfectly  warm  before  he  leaves  the  house. 
If  he  is  chilly  when  he  starts  for  his  airing,  his  power  of 
resisting  external  cold  is  very  much  impaired.  Different 
exercises  should  be  devised  by  which  the  muscles  of  the 
arms,  chest,  and  back  may  be  brought  into  action;  and, 
where  the  strength  permits,  quiet  outdoor  games  should 
be  encouraged.    Shampooing  must  not  be  forgotten;  by 


DIET 


299 


this  means  the  development  of  the  muscles  is  aided  and 
the  action  of  the  skin  promoted.  It  should  be  practised 
every  morning  after  the  bath. 

Indoors,  free  ventilation  must  be  maintained,  while  every 
care  is  taken  to  avoid  draughts.  In  winter  it  is  im- 
portant that  the  rooms  be  kept  at  an  even  temperature, 
and  that  the  passages,  if  possible,  bo  warmed.  If  this  is 
impracticable,  some  extra  clothing  should  be  put  on  in 
bad  cases  before  the  child  is  allowed  to  pass  from  one 
room  to  another. 

The  action  of  the  skin  must  be  promoted  by  warm 
clothing,  and  by  rapid  sponging  with  water  as  hot  as  it 
can  be  borne.  In  every  case  of  lung  consolidation  cold 
baths  must  be  forbidden.  The  shock  produced  by  the 
first  contact  with  cold  water  at  once  drives  the  blood  from 
the  surface  to  the  interior,  and  causes  a  sudden  increase  of 
the  strain  upon  the  vessels  of  the  lungs  as  well  as  of  the 
other  viscera.  Pulmonary  congestion  may  be  produced  by 
this  means,  and  the  danger  of  haemoptysis  is  increased. 

The  diet  of  the  child  should  be  arranged  as  described 
under  the  head  of  prevention,  four  small  meals  being 
preferable  to  three  larger  ones  in  the  day.  Plenty  of  new 
milk  is  essential,  and  should  always  be  given  undiluted  if 
it  can  be  borne.  Sometimes,  however,  in  these  cases  there 
is  a  tendency  to  acidity  of  the  stomach.  This  can  be 
corrected  by  the  addition  of  lime-water,  or  of  fifteen  or 
twenty  drops  of  the  saccharated  solution  of  lime  to  the 
milk.  On  account  of  the  debility  of  the  digestive  organs, 
which  is  so  common  in  this  disease,  it  is  necessary  to 
exercise  great  care  in  the  selection  of  the  diet.  The 
simplest  articles  of  food  are  the  best,  as  plain  roast  beef 
or  mutton,  with  gravy,  mealy  potatoes  well  mashed,  milk, 
and  strong  beef  or  mutton  tea,  free  from  grease.  Clear 
turtle  soup  is  exceedingly  digestible  and  nutritious.  If 
eggs  are  allowed  they  should  be  lightly  boiled  or 
poached,  or  they  may  be  beaten  up  with  warm  milk. 


300  CHRONIC  PULMONARY  TUBERCULOSIS 

Farinaceous  food  should  enter  into  tlie  diet,  but,  on 
account  of  its  tendency  to  undergo  fermentation  and 
produce  acid,  its  effects  must  be  carefully  watched, 
and  no  more  should  be  given  than  can  with  safety  be 
digested.  Often  the  appetite  is  very  capricious,  and 
there  is  a  disgust  for  meat  and  for  the  plainer  articles  of 
food,  which  it  is  very  difficult  to  overcome.  In  such  cases 
frequent  changes  should  be  made  in  the  diet,  tempting  the 
appetite  with  a  small  bird,  as  a  quail  or  a  snipe ;  with  fish, 
as  turbot,  cod,  or  boiled  sole,  or  with  raw  oysters.  The 
addition  of  alcohol  is  often  useful  in  stimulating  the 
appetite  :  weak  burgundy  and  water,  or  a  large  wine-glass- 
ful of  light  bitter  ale,  may  be  given  to  a  child  of  six  or 
seven  years  old,  with  one  of  his  meals.  The  occasional 
administration  of  two  or  three  grains  of  hydrargyrum  cum 
creta  with  a  little  powdered  rhubarb  will  often  improve 
the  appetite  when  this  is  failing;  or  a  drop  of  dilute 
hydrocyanic  acid  with  five  grains  of  bicarbonate  of  soda 
may  be  given  in  a  bitter  infusion,  as  infus.  chirettse,  three 
times  in  the  day."^  The  mineral  acids  in  bitter  infusion 
are  also  of  service,  but  in  the  case  of  a  child  the}^  are,  as 
a  rule,  inferior  in  value  to  the  alkaline  medicines  just 
mentioned. 

A  careful  watch  must  be  kept  over  the  condition  of  the 
bowels,  for  our  hopes  of  improving  the  nutrition  of  the 
body  depend  entirely  upon  the  accuracy  of  the  per- 
formance of  the  digestive  functions.  Violent  purgatives 
should  be  avoided.  If  there  is  constipation,  an  occasional 
dose  of  castor  oil,  or  decoction  of  aloes,  will  be  sufficient 
to  produce  an  evacuation.  The  more  common  condition, 
however,  is  one  in  which  there  is  a  tendency  to  relaxation 
of  the  bowels,  three  or  four  light -coloured  offensive 
motions  being  passed  in  the  course  of  the  day.  In  these 
cases  opium  is  a  most  valuable  medicine,  and  should  be 
given  with  aromatic  sulphuric  acid  if  the  tongue  is  clean  ; 
*  Suitable  to  a  child  five  years  old. 


COD-LIVEE,  OIL 


301 


or,  if  there  is  inucli  straining,  with  mucus  in  the  stools 
and  a  furred  tongue,  it  can  be  given  with  small  doses  of 
castor  oil. 

When  the  digestive  organs  have  been  brought  into  a 
healthy  state,  cod-liver  oil  and  tonics  become  necessary 
to  continue  the  improvement.  These  are  as  beneficial  now 
as  they  were  injurious  so  long  as  there  remained  any 
functional  derangement  of  the  alimentary  canal.  Cod- 
liver  oil  is  of  immense  service,  but  care  must  be  taken  to 
proportion  the  quantity  given  to  the  digestive  power  of 
the  patient.  At  first  half  a  teaspoonful  is  a  sufficient 
dose ;  it  should  be  taken  three  times  a  day  after  meals  in 
a  little  milk,  orange  wine  and  water,  or,  better  still,  in  a 
cold  infusion  of  orange-peel.  The  dose  can  be  afterwards 
increased,  but  the  stools  should  be  examined  from  time  to 
time  for  undigested  oil.  I  prefer  the  common  brown  oil, 
and  often  order  it  to  be  taken  in  a  teaspoonful  of  the 
pancreatine  wine  prepared  by  Messrs.  Savory  and  Moore. 
This  preparation  is  a  valuable  one  for  children  who  have 
only  a  limited  power  of  digesting  fats.  The  oil  often 
agrees  better  when  combined  with  a  dose  of  creasote. 
At  the  Victoria  Park  Hospital  we  have  found  that  the 
mixture  of  the  two  remedies  seems  to  increase  the  digesti- 
bility of  both.  For  a  child  of  five  or  six  years,  I  give  a 
teaspoonful  of  the  oil  with  five  to  ten  minims  of  beech- 
wood  creasote  twice  or  three  times  a  day  after  food.  I 
have  found  no  advantage  from  pushing  the  dose  of  either 
drug  beyond  this  point. 

Under  the  head  of  tonics,  iron  takes  the  first  place.  It 
may  be  given  as  vinum  ferri ;  liquor  ferri  pernitratis  with 
dilute  nitric  acid ;  the  ammonio-citrate ;  the  potassio-tar- 
trate ;  reduced  iron  (in  doses  of  half  a  grain  twice  a  day)  ; 
or  the  syrups  of  the  phosphate  or  iodide.  If  the  syrup 
be  objected  to,  the  iodide  may  be  conveniently  given  as 
in  the  following  mixture  : — 


302  CHRONIC  PULMONARY  TUBERCULOSIS 

P>    Ferri  Tartarati,  gr.  v, 

Potass.  lodidi,  gr.  iss. 

Aquae  destillatse,  ^ss.    M.    Ft.  haustus. 
To  be  taken  three  times  a  day. 

Iron  has  been  objected  to,  as  tending  to  produce  irrita- 
tion and  congestion  of  the  lungs  and  haemoptysis.  If, 
however,  it  is  not  given  in  too  large  doses,  such  effects  in 
children  are  seldom  seen  to  follow  its  employment.  On 
the  contrary,  where  the  condition  of  the  stomach  and 
bowels  is  satisfactory,  its  use  is  generally  followed  with 
very  great,  if  only  temporary,  advantage. 

Besides  iron,  other  tonics  may  be  given ;  as  quinine, 
which  may  be  usefully  combined  with  iron,  as  in  the 
double  citrate  of  iron  and  quinine  (dose,  five  grains  three 
times  a  day  suspended  in  glycerine) ;  decoction  of  cin- 
chona ;  tannic  acid,  either  in  a  mixture  with  dilute  nitric 
acid,  or  as  the  decoction  of  oak-bark ;  and  the  tincture  of 
nux  vomica.  All  these  may  be  tried,  and  sometimes  one, 
sometimes  another,  will  appear  to  be  beneficial. 

With  regard  to  the  special  treatment  of  the  lung  affec- 
tion— so  long  as  there  is  fever,  with  dry  cough  or  scanty 
expectoration,  and  tightness  or  oppression  of  the  chest, 
stimulant  expectorants  are  inadmissible.  No  lowering 
measures  should  be  employed,  it  is  true;  but  while,  on 
the  one  hand,  we  should  avoid  all  means  calculated  to 
increase  the  depression  of  strength,  we  should  not,  on  the 
other  hand,  be  too  eager  to  administer  drugs,  the  action 
of  which  would  be  to  increase  the  irritation  of  a  mucous 
membrane  already  in  a  state  of  active  congestion.  Opium, 
although  it  allays  for  a  time  the  irritability  of  the  bron- 
chial tubes,  must  be  given  with  judgment.  It  is  unwise  to 
hinder  expectoration,  for  the  secretions  are  retained  in  the 
tubes  and  act  as  a  source  of  continued  irritation.  In  such 
cases  we  shall  best  relieve  the  engorged  state  of  the  lung 
by  the  administration  of  remedies  tending  to  produce  a 
copious  secretion  from  the  congested  mucous  membrane. 


COUGH  MIXTURES 


303 


The  child  should  be  confined  to  bed,  or  at  any  rate  to  one 
room ;  his  chest  should  be  kept  covered  with  hot  linseed- 
meal  poultices  frequently  renewed;  and  a  mixture  such 
as  the  following  should  be  administered  every  three 
hours  after  food : — 

5o    Vini  Antimonialis,  mv. 
Villi  Ipecaciianhse,  miij, 
Sp.  .3Etheris  Nitrosi,  Tax\^, 
Liq.  Ammonise  Acetatis,  5ss, 
Aq.  Carui  ad  5iij.    M.    Ft.  haustus. 

After  the  cough  has  become  looser,  and  the  oppression 
of  the  chest  has  subsided,  expectorants  with  small  doses 
of  morphia  may  be  given  three  times  a  day : — 

Sp.  Ammonise  Aromat.,  mv, 

Vin.  Ipecacuanhse,  mv, 

Liq.  Morphise,  miij, 

Syrupi  Limonis,  5ss, 

Aq.  ad  5iij.    M.    Ft.  haustus. 

And  afterwards,  when  the  secretion  is  free,  and  the  fever 
has  subsided,  an  astringent  may  be  prescribed : — 

Jjb    Liq.  Ferri  Pernitratis, 

Acidi  Nitrici  diluti,  aa  mij, 

Liq.  Morpbise,  -nuij, 

Oxymel  Scillse,  mxxv, 

Aq.  ad  5iij.    M.    Ft.  haustus. 
To  be  taken  three  times  in  a  day  after  food. 

On  account  of  the  derangement  of  the  stomach,  which 
is  so  apt  to  be  produced  by  even  small  doses  of  the  nau- 
seating expectorants,  such  as  ipecacuanha  and  squill,  it  is 
advisable  to  combine  them  with  tonics  when  the  state  of 
the  patient  permits.  In  this  way  they  are  better  borne  by 
the  stomach,  and  cause  less  impairment  of  the  appetite. 
The  alkaline  mixture  should  not  be  continued  too  long : 
when  the  secretion  is  quite  free,  as  shown  by  the  looseness 
of  the  cough,  the  ease  of  expectoration,  und  the  absence 


304  CHRONIC  PXTLMONARY  TTJBERCULOSIS 


of  fever,  astringents  are  required  to  dry  np  the  secretion, 
and  give  tone  to  the  relaxed  mucous  membrane. 

Antiseptic  inhalations  have  lately  come  much  into  favour. 
The  air  of  the  room  at  night  may  be  impregnated  with  the 
fumes  of  tar,  creasote,  or  carbolic  acid,  by  means  of  a 
vaporising  apparatus,  such  as  Dr.  E.  J.  Lee's  useful 
"  Steam  Draught  Inhaler."  In  the  daytime  various  anti- 
septics may  be  inhaled  for  an  hour  at  a  time  through  a 
perforated  metal  respirator.  Dr.  Coghill,  who  has  devised 
a  convenient  form  of  instrument,  combines  two  drachms 
each  of  ethereal  tincture  of  iodine  and  carbolic  acid,  with 
one  drachm  of  creasote  and  one  of  rectified  spirit.  Ten 
drops  of  this  preparation  are  poured  upon  a  piece  of  cotton 
wool  and  used  in  the  respirator.  The  inhalation  may  be 
repeated  several  times  in  the  day.  Its  effect  is  to  diminish 
the  violence  of  the  cough  and  render  expectoration  easier. 
With  the  same  object  ten  drops  of  the  oil  of  cinnamon 
may  be  inhaled  through  the  respirator  at  frequent  intervals 
throughout  the  day.  This  oil  has  been  said  to  have  a 
distinct  germicidal  effect  upon  the  bacillus.  However  this 
may  be  there  can  be  no  doubt  about  its  value  in  reducing 
secretion  and  quieting  the  attacks  of  cough.  Its  action  is 
no  doubt  the  same  as  that  of  the  creasote  already  recom- 
mended. I  usually  continue  its  administration  until  the 
body  of  the  patient  is  impregnated  with  the  cinnamon  odour. 

In  cases  where  we  have  reason  to  believe  the  consolida- 
tion to  be  owing  to  cheesy  pneumonic  deposits,  we  must 
do  all  in  our  power  to  hasten  the  absorption  of  the  caseous 
mass.  Removal  to  a  dry  bracing  spot  is  at  once  indicated, 
and  as  soon  as  possible  the  child  should  begin  a  course  of 
alkaline  medicines.  Sir  Andrew  Clark  recommends  that 
the  urine  be  kept  alkaline  for  a  time.  The  hypophosphites 
— especially  the  hypophosphite  of  lime — are  of  peculiar 
value  in  these  cases.  When  softening  of  the  deposit  is 
suspected,  and  there  is  fever  with  wasting,  the  beneficial 
influence  of  these  remedies  is  often  very  surprising. 


COUNTER-IRRITANTS 


305 


Counter-irritation  in  children  must  be  used  cautiously. 
So  long  as  there  is  fever,  with  dry  cough,  &c.,  hot  linseed- 
meal  poultices  are  the  best  applications  ;  and  these,  com- 
bined with  the  measures  described  above,  soon  relieve  the 
more  acute  symptoms.  Irritants  applied  to  the  chest 
appear  to  be  most  useful  when  the  consolidation  is  pneu- 
monic in  character.  In  such  cases  a  liniment  of  croton  oil 
(5j  in  33  of  linimentum  saponis)  may  be  rubbed  into  a 
limited  spot  twice  a  day  till  pustulation,  and  then  once  a 
day  for  a  week  ;  or  the  chest  may  be  painted  over  the  seat 
of  disease  with  linimentum  iodi.  These  measures  are, 
however,  only  applicable  when  the  pyrexia  is  slight;  if 
there  be  much  heat  of  skin  counter-irritants  must  not  be 
employed. 

In  the  last  stage  of  the  disease  we  must  watch  the  state 
of  the  digestive  organs,  and  endeavour  to  remove  any  con- 
ditions which  would  tend  to  increase  the  debility.  If  the 
cough  produces  retching  and  sickness,  small  doses  of 
arsenic,  such  as  one  drop  of  Fowler's  solution,  given  with 
dilute  nitric  acid  and  a  few  minims  of  liquor  morphiae 
will  usually  afford  relief.  If  haemoptysis  occur,  the  child 
must  be  kept  perfectly  quiet  in  bed ;  ten  drops  of  the  liquid 
extract  of  ergot  should  be  administered  three  times  a  day, 
with  laxative  doses  of  Epsom  salts  if  the  bowels  are  not 
ulcerated,  and  fluids  must  only  be  given  in  small  quantities. 
Profuse  sweating  is  best  controlled  by  belladonna  given  in 
sufficient  doses.  A  night  draught  containing  ten  drops 
of  the  tincture  may  be  given  without  hesitation  to  a  child 
of  four  years  old,  and  will  have  greater  influence  than 
smaller  doses  of  the  drug  given  more  frequently. 

In  cirrhosis  of  the  lung  and  fibroid  phthisis  disinfectant 
and  stimulating  inhalations  are  of  great  service.  When- 
ever an  offensive  smell  from  the  breath  indicates  the 
presence  of  putrefying  secretions  in  the  air-tubes,  inhala- 
tions of  steam  impregnated  with  creasote  or  carbolic  acid 
(twenty  drops  to  the  pint  of  boiling  water)  should  be 

20 


306  CHRONIC  PULMONARY  TUBERCULOSIS 

ordered ;  and  the  air  of  tlie  room  should  be  thoroughly 
saturated  with  the  fumes  of  creasote  or  other  disinfectant 
by  means  of  a  vaporiser.  Iron  and  quinine  in  large  doses 
are  well  borne  in  these  cases,  and  should  be  given  with 
morphia.  Emetics  must  not  be  forgotten.  A  quickly 
acting  emetic,  by  producing  violent  contractions  of  the 
diaphragm,  will  often  cause  enormous  quantities  of  offen- 
sive purulent  matter  to  be  brought  up.  If  the  loaded 
tubes  are  thus  evacuated  in  the  morning,  the  patient  will 
pass  the  day  in  much  greater  comfort,  and  his  appetite  and 
digestion  will  be  improved.  Cod-liver  oil — especially  if 
given  with  pancreatine  wine — is  of  much  value  in  these 
cases.  When  dropsy  comes  on,  tonics  such  as  strychnia 
and  iron  should  be  administered  at  once. 


CHAPTER  XI 


TUBERCULOSIS  OF  LYMPHATIC  GLANDS 
iHRONIC  tuberculous  enlargement  of  the  lymphatic 


glands  is  a  common  lesion  in  the  child.  It  may  affect 
not  only  the  external  glands,  but  also  those  occupying  the 
thoracic  and  abdominal  cavities.  While,  however,  in  the 
case  of  the  external  glands,  no  other  ill  effects  follow  than 
those  necessarily  attendant  upon  the  presence  of  a  local- 
ised tuberculous  swelling,  in  the  case  of  the  bronchial  and 
mesenteric  glands  other  evils  are  induced.  These  bodies 
— enclosed  as  they  are  in  cavities,  and  in  contact  with 
compressible  organs — produce  by  their  pressure,  when  en- 
larged, secondary  disturbances  which  vary  according  to  the 
organ  whose  function  is  thus  interfered  with,  and  according 
to  the  more  or  less  yielding  material  of  which  the  walls  of 
the  cavity  are  composed.  Enlargement  of  the  bronchial 
glands  will  thus  produce  more  serious  consequences — 
owing  to  the  resisting  parietes  of  the  chest — than  the 
same  condition  of  the  mesenteric  glands  which  are  confined 
by  the  more  distensible  wall  of  the  belly. 

The  manner  in  which  the  lymphatic  glands  become 
inoculated  with  the  tubercle  bacillus  has  been  already  ex- 
plained (see  p.  251).  Infection  of  the  glands  is  the  first 
stage  in  the  progress  of  the  microbes  from  the  surface  to 
the  interior  of  the  body.  In  many  cases,  fortunately,  they 
go  no  further.  If  the  resisting  power  of  the  system  be 
adequate,  and  the  number  of  the  organisms  not  unduly 


308  TUBERCULOSIS  OF  LYMPHATIC  GLANDS 

large,  no  ill  consequences  follow.  It  may  be  said  of  all 
glands,  but  especially  of  those  which  occupy  the  cervical 
region,  that  in  most  cases  the  tuberculosis  remains  a  mere 
local  disease  in  the  glands  first  attacked,  and  the  system 
escapes  general  infection. 

The  glands  are  not  all  equally  affected.  Some  remain 
perfectly  healthy,  while  others  are  diseased ;  some  which 
are  diseased  remain  small,  while  others  undergo  consider- 
able enlargement. 

As  seen  in  the  neck,  caseous  tuberculous  glands  are 
round  or  oval,  hard,  uneven  on  their  surface,  and  their 
outline  is  irregular.  They  are  not  tender,  and  the  skin 
over  them  is  colourless,  and  is  not  adherent.  Sometimes 
several  glands  become  enlarged  and  unite,  forming  a  mass 
the  separate  parts  of  which  are  connected  by  thickened 
and  condensed  cellular  tissue. 

Cheesy  glands  may  remain  for  a  long  time  unchanged, 
and  while  thus  inactive  are  not  necessarily  hurtful  unless 
they  cause  interference  with  function  in  neighbouring 
organs  by  pressure  upon  parts  around.  Sooner  or  later, 
however,  one  of  two  changes  usually  takes  place : — either 
the  cheesy  matter  softens,  sets  up  inflammation  around 
and  is  discharged ;  or  the  fluid  part  of  the  caseous  mass 
is  absorbed,  and  the  gland  shrinks  and  becomes  hardened 
by  the  deposition  of  earthy  salts.  The  first  of  these 
changes  is  common  in  the  glands  of  the  neck,  while  in 
the  mesenteric  glands  the  usual  termination  is  that  by 
shrinking  and  petrifaction.  In  rare  cases,  complete  reso- 
lution and  absorption  of  the  cheesy  matter  may  take  place  ; 
or  the  gland  may  be  converted  into  a  fibrous  mass  by 
thickening  of  all  the  trabeculse  of  the  reticulum. 

When  a  caseous  gland  softens,  the  process  usually 
begins  in  the  centre,  although  isolated  points  at  the  cir- 
cumference may  first  undergo  this  change.  These,  on 
section  of  the  gland,  are  sometimes  seen  to  be  connected 
by  prolongations  of  softening  with  the  softened  centre. 


THE  BRONCHIAL  GLANDS 


309 


Evacuation  of  the  liquefied  matter  eventually  takes  place. 
In  the  cervical  region  the  softened  glands  discharge  their 
contents  through  the  skin.  The  same  thing  may  occur 
with  the  bronchial  glands,  but  is  not  common.  As  a  rule, 
the  deeply  seated  glands,  such  as  those  of  the  mediastinum 
and  mesentery,  rupture  into  the  nearest  hollow  viscus. 
The  bronchial  glands  perforate  the  trachea  or  a  large  air- 
tube;  while  the  mesenteric  glands,  when  suppurating, 
empty  themselves  into  the  general  peritoneal  cavity,  or  into 
the  intestine. 


Tuberculosis  of  the  Bronchial  G-lands. 

Judging  from  the  facility  with  which  the  superficial 
glands  swell  up  in  the  child,  as  a  result  of  casual  irrita- 
tion of  neighbouring  parts,  we  may  infer  that  a  similar 
enlargement  will  occur  under  like  circumstances  in  glands 
more  deeply  placed.  The  bronchial  glands  are,  no  doubt, 
influenced  by  the  presence  of  irritation  in  parts  in  which 
their  lymphatics  originate  ;  and  in  children  who  are  subject 
to  repeated  attacks  of  pulmonary  catarrh,  or  broncho- 
pneumonia, evidence  of  change  in  these  glands  can  often 
be  detected.  The  same  thing  is  noticed  in  most  cases 
of  whooping-cough.  When  thus  acutely  enlarged,  the 
swelling  usually  subsides  as  the  irritation  lessens.  If 
it  become  chronic,  the  enlargement  is  due  almost  always 
to  tubercular  infection.  Unlike  the  same  lesion  as  it 
occurs  in  the  neck,  suppuration  is  rare,  but  few  patho- 
logical alterations  are  more  common  in  the  post-mortem 
room  than  enlargement  and  caseation  of  glands  in  the 
mediastinum. 

The  seat  of  the  enlarged  gland  is  at  the  bifurcation  of 
the  trachea,  and  therefore  behind  the  first  bone  of  the 
sternum  and  a  little  below  it.  Besides  these,  however,  the 
glands  accompanying  the  bronchial  tubes  into  the  interior 


310  TUBERCULOSIS  OF  BRONCHIAL  GLANDS 

of  the  lung  may  be  also  increased  in  size,  althougli 
usually  to  a  less  extent ;  and  it  is  not  uncommon  to  find 
them  larger  than  natural  as  far  as  the  third  or  fourth 
divisions  of  the  air- tubes.  A  mass  formed  of  these 
enlarged  glands  may  occupy  the  anterior  mediastinum, 
extending  from  the  top  of  the  sternum  to  the  base  of  the 
heart. 

Tuberculosis  of  the  bronchial  glands  is  not  confined  to 
children  in  whom  there  is  actual  disease  of  lung.  It  may 
be  found  in  subjects  who  have  shown  no  sign  of  pulmonary 
derangement,  and  in  whom  the  most  careful  examination 
of  the  lungs  may  fail  to  detect  any  evidence  of  pulmonary 
mischief.  Still,  we  cannot  view  with  indifference  the 
presence  of  a  tuberculous  mass  however  strictly  localised. 
The  disease  may  spread  directly  from  the  gland  to  the 
lung  tissue  in  contact  with  it,  or  may  lead  to  a  general 
infection  of  the  system  as  has  been  already  described  (see 
page  253). 

Symptoms. — Children  in  whom  this  lesion  exists  are 
usually  thin  and  pale.  They  are  also  generally  languid 
and  indolent,  preferring  quiet  amusements  to  the  more 
boisterous  games,  l^utrition  is  impaired  as  a  consequence 
of  the  various  catarrhal  disorders  to  which  their  excep- 
tional sensitiveness  to  changes  of  temperature  renders 
them  peculiarly  prone.  Attacks  of  pulmonary  and  gastric 
catarrh,  and  of  catarrhal  diarrhoea,  are  frequent  during 
the  changeable  seasons  of  the  year.  Owing  to  these 
attacks,  the  digestive  organs  are  not  very  robust;  but 
between  them  the  child's  appetite  may  be  good,  and  the 
digestion  fairly  performed.  A  tuberculous  gland,  so  long 
as  it  remains  inactive,  does  not  directly  give  rise  to 
elevation  of  temperature ;  but  the  child  is  subject  to 
irregular  attacks  of  fever,  as  a  consequence  of  the  catarrhal 
derangements  above  referred  to.  If  softening  in  the 
cheesy  mass  occur,  the  event  is  at  once  marked  by  an 
increase  in  the  heat  of  the  body. 


SPECIAL  SYMPTOMS 


311 


The  special  symptoms  arising  from  enlargement  of  the 
bronchial  glands  are  all  pressure  signs  due  to  the 
encroachment  of  the  swollen  body  upon  the  parts  around. 
These  special  symptoms  may  best  be  grouped  according 
to  the  causes  which  produce  them.  Thus  the  glands  by 
their  enlargement  may  press  upon  the  blood-vessels,  the 
nerves,  and  the  air-passages. 

Pressure  upon  the  superior  vena  cava  or  upon  either 
innominate  vein  interferes  with  the  return  of  blood  to 
the  heart.  As  a  consequence,  we  find  more  or  less  lividity 
of  the  face  and  neck,  and  dilatation  of  the  superficial 
veins,  not  only  in  those  parts,  but  also  over  the  front  of 
the  chest,  and  often  in  the  shoulders  and  arms.  A  certain 
amount  of  heaviness  and  stupor  may  be  produced  by  the 
interference  with  the  return  of  blood  from  the  brain ; 
and  if  the  pressure  be  great,  or  the  quality  of  the  blood 
much  impoverished,  puffiness  or  even  oedema  of  the  face 
may  be  found,  first  appearing  and  being  most  marked 
about  the  eyelids.  If  only  one  of  the  innominate  veins 
is  exposed  to  pressure,  the  symptoms  are  limited  to  one 
side  only.  Enlargement  of  the  veins  of  one  side  of  the 
face  and  neck,  with  a  prominent  jugular  vein  on  that  side, 
should  always  lead  us  to  suspect  the  existence  of  enlarged 
bronchial  glands.  The  venous  engorgement  is  especially 
noticeable  during  coughing. 

If  the  congestion  is  very  great,  rupture  of  small  vessels 
may  take  place,  and  bleeding  occur  from  the  nose  or  into 
the  lungs.  The  former  is  common,  but  the  latter  is  difii- 
cult  to  ascertain,  for  children  almost  invariably  swallow 
blood  coming  up  from  the  lungs.  In  a  child  the  discharge 
of  blood  from  the  mouth  during  coughing  is  seldom 
evidence  of  haemoptysis.  It  is  almost  always  the  result 
of  epistaxis,  the  blood  flowing  down  into  the  back  of  the 
throat  through  the  posterior  nares. 

When  the  nerves  passing  through  the  chest  are  com- 
pressed, one  of  the  earliest  indications  of  such  pressure  is 


312  TTJBEECULOSIS  OF  BEONCHIAL  GLANDS 

a  peculiar  character  of  the  cough.  The  cough  becomes 
spasmodic,  occurring  irregularly  in  paroxysms  like  those 
of  pertussis,  lasting  only  a  short  time,  and  ending  some- 
times, although  rarely,  in  a  crowing  inspiration.  There 
is  seldom  any  vomiting.  Sometimes  the  cough  is  hoarse 
and  dry  ;  at  others  it  is  moist  with  a  rattling  of  mucus  ; 
at  others,  again,  its  quality  is  unchanged,  and  presents 
nothing  to  attract  attention. 

The  voice,  like  the  cough,  may  be  altered  in  character, 
but  not  usually,  unless  the  disease  is  far  advanced.  It 
may  become  hoarse  or  thick,  or  even  partially  extinct,  and 
these  different  conditions  frequently  alternate  with  one 
another. 

Serious  pressure  upon  the  trachea  or  a  large  bronchus 
induces  attacks  of  distressing  dyspnoea.  These  attacks 
are  usually  spoken  of  as  asthmatic."  The  face  becomes 
livid,  the  countenance  haggard,  and  the  skin  damp.  As 
a  rule  the  dyspnoea  affects  both  inspiration  and  expiration, 
although  it  is  more  marked  in  the  latter.  With  each 
breath  there  is  a  stridor,  and  the  soft  parts  of  the  chest 
sink  in  deeply  in  inspiration.  Exertion  of  any  kind  in- 
creases the  dyspnoea.  The  voice  is  unaffected.  When 
these  symptoms  are  met  with,  especially  if  at  the  same 
time  there  are  signs  of  pressure  upon  the  vessels  of  the 
chest,  we  have  reason  to  fear  suppuration  of  the  glands 
with  the  formation  of  an  abscess.  If  this  be  the  case, 
perforation  of  the  air-passage  is  not  unlikely  to  occur. 
The  dyspnoea  is  then  extreme  with  marked  cyanosis ;  the 
cough  is  convulsive,  and  the  child  clutches  at  his  throat 
and  shows  every  symptom  of  distress.  The  pulse  and 
respiration  become  irregular  before  death. 

If  pulmonary  catarrh  occur  in  a  child  who  is  suffering 
from  the  above  symptoms,  the  lividity  is  deepened,  the 
dyspnoea  aggravated,  the  cough  becomes  more  constant 
and  hacking,  and  the  apparent  imminence  of  the  danger 
excites  the  liveliest  apprehensions.     Indeed,  if  prompt 


PHYSICAL  SIGNS 


318 


measures  are  not  resorted  to  for  the  relief  of  the  catarrh, 
death  may  take  place  with  some  suddenness. 

Physical  signs. — The  enlarged  glands  are  seated  at  the 
bifurcation  of  the  trachea,  and  therefore  behind  the  first 
bone  of  the  sternum.  On  percussion  there  is  dulness  at 
that  spot,  which  may  extend  to  a  variable  distance  on 
either  side  and  below.  It  sometimes  reaches  from  the 
sternal  notch  as  far  as  the  base  of  the  heart.  Occasionally 
there  is  dulness  also  between  the  scapulae,  but  this  is  not 
always  found,  on  account  of  the  thickness  of  lung  which 
lies  between  the  glands  and  the  posterior  wall  of  the  chest. 
If  any  enlarged  glands  lie  underneath  the  anterior  margins 
of  the  lungs,  a  cracked-pot "  sound  may  be  heard  on  per- 
cussion over  the  first  three  ribs.  This,  however,  on  account 
of  the  natural  pliancy  of  the  chest  walls  in  children,  is  a 
common  circumstance,  and  is  not  necessarily  a  sign  of 
disease. 

The  auscultatory  signs  are  due  partly  to  the  effects  of 
pressure  of  the  enlarged  glands  upon  the  trachea  and 
bronchi ;  partly  to  the  unnatural  distinctness  with  which 
the  breath- sounds  are  conveyed  to  the  surface,  for  an 
artificial  medium  of  conduction  is  formed  between  the 
tubes  and  the  wall  of  the  chest. 

When  the  lower  part  of  the  trachea  is  pressed  upon,  a 
loud  stridor  is  heard  during  respiration.  This  stridor  is 
usually  intermittent.  It  is  conducted  to  all  parts  of  the 
chest,  and  to  the  stethoscope  quite  covers  the  normal 
breath- sound.  Upon  either  bronchus  pressure,  if  consider- 
able, causes  weakness  of  the  respiratory  sound  in  the 
corresponding  lung,  especially  at  the  base ;  for  a  certain 
amount  of  collapse  of  the  inferior  lobes  of  the  lung  may 
take  place,  with  sinking  in  of  the  lower  part  of  the  thoracic 
wall  on  that  side. 

If  without  actual  pressure  the  glands  come  into  close 
contact  with  the  bronchi  on  one  side,  and  the  chest  wall 
on  the  other,  the  breath- sounds  are  tubular  with  long 


314  TUBERCULOSIS  OF  BRONCHIAL  GLANDS 

ringing  rhonchus  in  front,  and  sometimes  between  the 
scapulae  behind;  powerful  ^i^asi-pectoriloquous  broncho- 
phony may  also  be  produced.  The  vocal  resonance  also  is 
bronchophonic. 

At  the  supra- spinous  fossae  the  sounds  may  be  weak, 
bronchial,  or  even  cavernous,  and  these  different  conditions 
may  alternate  irregularly  with  one  another.  If,  however, 
there  be  no  disease  of  the  lung,  the  hollow  quality  of  the 
breath-sound  is  very  much  diminished,  or  may  even  be 
quite  lost  when  the  mouth  is  open. 

If  the  gland  presses  upon  a  large  vein,  such  as  the 
descending  vena  cava,  or  the  left  innominate  vein,  a  hum 
will  be  heard  with  the  stethoscope  at  that  point,  and 
compression  of  the  pulmonary  artery  produces  a  systolic 
murmur,  heard  at  the  second  left  interspace. 

In  cases  where  the  glandular  swelling  occurs  as  a  com- 
plication of  pulmonary  phthisis,  the  more  prominent  sym- 
ptoms are  due  to  the  condition  of  the  lung ;  so  that  unless 
the  enlargement  be  great,  the  disease  in  the  glands  is  apt 
to  be  overlooked.  Moreover,  in  such  cases  the  physical 
signs  arising  from  the  lungs  are  often  perverted  and  ex- 
aggerated by  this  condition  of  the  glands,  as  has  already 
been  described. 

The  usual  termination  of  enlarged  bronchial  glands  is 
that  by  shrinking  and  petrifaction— a  mode  of  termination 
which  may  be  considered  equivalent  to  a  cure.  In  rare 
cases  they  soften  and  break  down  into  a  thick  purulent 
fluid,  which  may  be  evacuated  into  the  pleural  cavity,  or 
into  a  large  vessel,  causing  fatal  haemorrhage ;  or,  more 
commonly,  into  a  bronchial  tube.  Softening  of  the  glands 
is  usually  followed  by  a  general  infection  of  the  system, 
and  the  patient  dies  of  acute  tuberculosis. 

Diagnosis. — In  a  well-marked  case  the  signs  of  pressure 
upon  the  veins,  the  dulness  over  the  first  bone  of  the 
sternum  extending  to  a  variable  distance  on  each  side, 
and  the  paroxysmal  cough,  point  conclusively  to  caseation 


VENOUS  HUM 


315 


of  the  bronchial  glands.  The  peculiarity  of  the  cough  is, 
indeed,  often  the  first  symptom  leading  us  to  suspect  the 
nature  of  the  disease.  This  is  distinguished  from  the 
cough  of  pertussis,  which  it  so  much  resembles,  by  the 
absence  of  crowing  and  of  the  terminal  vomiting  or  glairy 
expectoration.  Such  a  cough,  if  unaccompanied  by  the 
auscultatory  signs  of  pulmonary  disease,  is  very  distinctive 
of  enlarged  bronchial  glands.  The  absence  of  these  auscul- 
tatory signs  is  very  important  in  the  diagnosis,  as  a 
morning  cough  of  a  very  similar  character  is  occasionally 
heard  in  cases  of  fibroid  induration  with  dilatation  of 
bronchi,  and  is  sometimes  also  characteristic  of  catarrhal 
pneumonia.  If  in  the  intervals  of  the  fits  of  coughing 
there  is  anything  approaching  to  an  asthmatic  seizure,  or 
the  slightest  percussion-dulness  at  the  top  of  the  sternum, 
little  doubt  can  remain  as  to  the  nature  of  the  disease. 
Alteration  in  the  quality  of  the  voice  often  accompanies 
the  characteristic  cough.  If  there  is  doubt  in  any  case, 
the  occurrence  of  signs  of  venous  pressure  at  once  changes 
our  suspicions  into  certainty. 

Well-marked  pressure  signs  are  not,  however,  present 
until  the  swelling  of  the  glands  has  become  considerable. 
At  an  earlier  period,  and  before  the  enlargement  has  be- 
come sufficiently  great  to  cause  symptoms  so  obvious,  the 
diagnosis  of  the  lesion  is  far  from  easy,  as  the  symptoms 
by  which  it  is  accompanied  are  few  and  obscure.  At  this 
time  much  assistance  can  be  gained  from  the  following 
experiment."^  If  the  child  be  made  to  bend  back  the 
head,  so  that  his  face  becomes  almost  horizontal,  and  the 
eyes  look  straight  upwards  at  the  ceiling  above  him,  a 
venous  hum,  varying  in  intensity  according  to  the  size 
and  position  of  the  diseased  glands,  is  heard  with  the 
stethoscope  placed  upon  the  upper  bone  of  the  sternum. 

^  See  a  paper  by  the  writer  "  On  the  Early  Diagnosis  of  Enlarged 
Bronchial  Glands,"  communicated  to  the  'Lancet' of  Augnst  14th, 
1875. 


316  TUBERCULOSIS  OF  BRONCHIAL  GLANDS 

As  the  chin  is  now  slowly  depressed,  the  hum  becomes 
less  loudly  audible,  and  ceases  shortly  before  the  head 
reaches  its  ordinary  position.  The  explanation  of  this 
phenomenon  appears  to  be  that  the  bending  back  of  the 
head  tilts  forward  the  lower  end  of  the  trachea,  which 
carries  with  it  the  glands  lying  in  its  bifurcation,  and  the 
left  innominate  vein,  as  it  passes  behind  the  first  bone  of 
the  sternum,  is  compressed  between  the  enlarged  glands 
and  the  bone.  In  cases  where  this  sign  has  been  noticed 
there  has  often  been  some  slight  dulness  over  the  manu- 
brium, leading  one  to  suspect  the  existence  of  enlarge- 
ment of  the  glands ;  and  the  occurrence  of  the  hum  thus 
produced  the  writer  always  considers  to  be  evidence  con- 
firmatory of  the  suspicion. 

The  experiment  does  not  succeed  in  cases  of  flat  chest 
when  there  is  no  reason  to  suspect  glandular  enlarge- 
ment, nor  can  the  hum  be  produced  by  the  thymus  gland 
in  a  healthy  child.  This  gland  is  immediately  behind  the 
sternum  in  front  of  the  great  vessels  ;  enlarged  bronchial 
glands  lie  behind  the  vessels  in  the  bifurcation  of  the 
trachea.  A  swelling  in  front  of  the  vessels  does  not 
appear  to  set  up  pressure  upon  the  vein  when  the  head  is 
bent  back  in  the  position  described.  The  writer  has 
examined  many  children  with  a  view  to  test  this  point, 
and  in  no  case  has  the  characteristic  hum  been  produced 
except  where  there  was  reason  from  other  symptoms 
to  suspect  the  presence  of  bronchial  glandular  enlarge- 
ment. 

The  following  cases  furnish  good  illustrations  of  the 
symptom  in  question  : — 

Arthur  P — ,  aged  eight  years,  had  had  scrofulous 
disease  of  the  knee-joint  for  twelve  months.  The  cervical 
glands  were  enlarged,  and  his  skin  generally  was  harsh 
and  dry.  For  two  months  his  breathing  had  been  short, 
although  he  had  had  no  spasmodic  attacks  of  dyspnoea. 
During  the  same  time  he  had  been  troubled  with  a  dry, 


ILLUSTRATIVE  CASES 


317 


hollow  cougli.  There  was  slight  dulness  at  the  left  supra- 
spinous fossa,  and  a  little  crepitating  rhonchus  was  heard 
there  at  the  end  of  inspiration.  There  was  no  dulness  on 
percussion  at  the  upper  part  of  the  breast-bone ;  but  when 
the  boy  held  his  head  back  so  as  to  turn  his  face  upwards 
to  the  ceiling,  a  loud  continuous  hum  was  heard  near  the 
left  edge  of  the  first  bone  of  the  sternum.  This  ceased 
when  the  chin  was  brought  down  again  into  the  natural 
position.  The  boy  had  no  swelling  of  the  cervical  veins, 
spasmodic  cough,  or  other  sign  of  enlarged  bronchial 
glands,  except  the  peculiar  and  characteristic  hollow, 
almost  cavernous  breathing  which  is  often  heard  in  such 
cases,  when  the  lips  are  closed,  over  the  upper  part  of 
each  lung.  This,  however,  disappeared  to  a  great  extent 
when  the  mouth  was  open. 

Alice  T — ,  aged  six  years,  a  pale,  thin  child,  had  been 
weakly  for  several  months,  and  had  been  getting  thinner. 
She  had  no  cough  to  speak  of.  On  stripping  the  child  to 
examine  her  chest,  it  was  noticed  that  the  superficial 
veins  at  the  upper  part  of  the  breast-bone  and  at  either 
side  were  unusually  visible.  The  veins  of  the  neck  were 
not  distended,  nor  was  there  any  enlargement  of  the 
cervical  glands.  The  percussion  note  on  the  first  bone  of 
the  sternum  was,  perhaps,  a  little  high-pitched.  When 
the  child  bent  her  head  well  backwards,  a  very  loud  con- 
tinuous roaring  sound  was  heard  over  the  first  two  sternal 
bones,  and  extended  to  the  articulation  of  the  second 
right  costal  cartilage.  The  sound  ceased  when  the  chin 
was  depressed  again.  There  was  no  dulness  in  the  inter- 
scapular region  behind. 

It  would  be  easy  to  multiply  illustrations  of  this  sym- 
ptom, for  slight  enlargement  of  the  bronchial  glands  is 
very  common  in  children.  In  order  that  the  hum  be  ca- 
pable of  being  produced  in  the  vein,  the  glands  of  the 
chest  must  be  moveable.  If  they  are  fixed,  and  at  some 
distance  from  the  sternum,  the  experiment  fails.  Thus, 


318  TUBERCULOSIS  OF   BRONCHIAL  GLANDS 

in  a  boy  aged  three  years,  the  subject  of  Ij^mphadenoma, 
who  died  in  the  East  London  Children's  Hospital,  there 
was  dulness  at  the  upper  part  of  the  breast-bone,  which 
was  continued  down  in  a  pyramidal  form  as  far  as  the 
base  of  the  heart.  No  venous  hum  was  heard  on  bending 
back  the  head.  On  examination  of  the  body  of  this 
child,  yellow  flattened  cheesy  masses  were  found  adherent 
to  the  inside  of  the  sternum,  and  others,  much  enlarged 
and  immoveable,  were  seen  filling  up  the  interval  below 
the  bifurcation  of  the  trachea.  In  this  case  the  alterna- 
tion in  the  position  of  the  head  did  not  set  up  pressure 
upon  the  vein,  as  the  glands,  being  fixed,  could  not  be 
carried  forward  against  the  vessel. 

The  venous  hum  thus  produced  by  bending  back  the 
head  seems  to  be  the  earliest  sign  of  enlargement  of  the 
bronchial  glands,  preceding  dulness  on  percussion,  and 
occurring  long  before  the  ordinary  pressure  signs  on 
which  the  diagnosis  of  the  lesion  is  usually  made  to 
depend. 

Prognosis, — Although  the  existence  in  the  mediastinum 
of  swollen  bronchial  glands  is  not  without  its  danger,  yet 
if  the  increase  in  size  be  moderate,  without  formidable 
pressure  signs,  and  especially  if  the  temperature  of  the 
body  be  natural,  we  have  reason  to  hope  that  by  suitable 
treatment  the  enlargement  may  be  reduced  before  it  has 
occasioned  any  ill  consequences  to  the  patient.  The 
existence  of  lividity,  dilatation  of  veins,  and  other  signs 
of  interference  with  the  circulation,  should  excite  anxiety ; 
and  attacks  of  asthma,  or  of  prolonged  spasm  of  the 
glottis,  are  of  very  unfavourable  augury.  If  in  such  cases 
the  symptoms  are  aggravated  by  the  presence  of  pulmonary 
catarrh  the  life  of  the  patient  is  often  placed  in  imminent 
danger. 

It  should  not  be  forgotten  that  acute  tuberculosis  may 
be  the  consequence  of  softening  in  these  glands ;  there- 
fore the  temperature  of  the  body  should  be  always  care- 


MESENTERIC  GLANDS 


319 


fully  taken,  and  any  abnormal  rise,  without  a  cause  being- 
discovered  to  account  for  it,  should  be  viewed  with  con- 
siderable apprehension. 

Tuberculosis  of  Mesenteric  Gtlands. 

Tuberculous  enlargement  of  the  mesenteric  glands,  or,  as 
it  used  to  be  called,  tahes  mesentericay  is  seldom  seen  in 
children  under  three  years  of  age,  and  even  in  older  chil- 
dren is  not  a  common  disease.  At  any  rate  it  is  compara- 
tively rare  to  find  enlargement  of  these  glands  so  great  as 
to  be  discoverable  by  the  touch  ;  and  unless  they  can  be  felt 
it  is  impossible  to  say  with  anything  approaching  to  cer- 
tainty that  they  are  enlarged  at  all.  Unless  enlarged, 
their  influence  upon  general  nutrition  is  probably  insig- 
nificant ;  for  although  they  may  not  be  quite  healthy,  they 
are  no  doubt  sufficiently  so  to  carry  on  their  functions 
fairly  well.  Therefore  if  no  increase  in  size  can  be  dis- 
covered, they  may  be  disregarded  in  estimating  the  pro- 
gnosis, or  determining  the  treatment  of  the  patient. 

When  diseased  the  glands  are  sometimes  separate,  but 
often  they  unite  to  form  an  irregular  nodular  mass  as 
large  as  the  fist  or  even  larger.  The  mass  is  situated  in 
front  of  the  vertebral  column.  If  the  mesentery  is  in- 
volved, the  tumour  is  fixed ;  if  the  mesentery  is  free,  the 
mass  can  be  moved  a  little  to  one  side  or  the  other. 

Symptoms. — In  cases  where  the  disease  is  moderate  in 
amount,  and  is  confined  entirely  to  the  glands  of  the 
mesentery  without  being  complicated  by  chronic  peritonitis 
or  any  lesion  of  the  bowels,  nutrition  may  be  little  if  at 
all  affected.  The  child  may  show  a  fair  amount  of  flesh  ; 
his  spirits  and  appetite  may  be  good,  his  temperature 
natural,  and  with  the  exception  perhaps  of  slight  want  of 
colour  there  may  be  little  in  his  appearance  to  suggest  a 
suspicion  of  ill-health.  If,  however,  as  often  happens, 
cheesy  enlargement  of  the  mesenteric  glands  is  conjoined 


320  TUBERCULOSIS  OP  MESENTERIC  GLANDS 

with  tuberculous  ulceration  of  the  bowels,  there  is  generally 
diarrhoea,  and  the  child  shows  all  the  signs  of  a  chronic 
interference  with  the  nutritive  processes.  He  wastes,  and 
grows  pale  and  feeble ;  his  face  looks  haggard ;  his  sleep 
is  disturbed ;  his  appetite  is  capricious,  and  there  is  often 
much  thirst.  At  night  the  bodily  temperature  is  usually 
higher  than  natural. 

The  local  symptoms  are  the  only  ones  of  any  value  in 
the  detection  of  disease  of  the  mesenteric  glands.  The 
belly  is  at  first  unchanged  in  shape,  and  even  as  the 
disease  advances  does  not  necessarily  become  more  pro- 
minent. On  the  contrary,  the  abdominal  wall  is  often 
natural ;  and  when  swollen  it  may  be  soft  and  easily 
depressed;  although  it  is  apt  to  become  tense  at  times 
from  the  accumulation  of  flatus,  especially  if  there  is  any 
accompanying  ulceration  of  the  bowels.  The  wall  may 
also  be  tense  when  the  size  of  the  glands  is  very  consider- 
ably increased.  The  degree  of  tension  of  the  parietes  is 
very  important  as  regards  the  detection  of  the  enlarge- 
ment. If  the  tension  be  very  great,  a  moderate  amount 
of  enlargement  may  escape  notice,  owing  to  the  resistance 
of  the  abdominal  walls,  which  will  not  allow  the  glands 
to  be  reached  by  the  finger ;  and  a  tumour  which  can  be 
easily  felt  at  one  visit  may  at  the  next  be  completely  con- 
cealed by  the  abdominal  inflation,  so  as  to  be  no  longer 
detectable  by  the  touch. 

In  the  commonest  form  of  glandular  enlargement  in  the 
mesentery  the  diseased  glands  are  small,  and  can  be  felt  as 
little  tumours  of  the  size  of  marbles  lying  deeply  in  front 
of  the  spine.  To  detect  them  we  should  place  the  child  on 
his  back,  with  his  knees  drawn  up  and  supported  by  an 
assistant,  his  shoulders  low,  and  his  head  raised  so  that  his 
chin  touches  his  chest.  If  now  we  make  gentle  pressure 
with  a  warm  hand  on  the  abdomen,  moving  our  fingers 
round  and  round  as  we  do  so,  very  small  lumps  can  be  felt 
if  the  wall  is  flaccid.    The  glands  are  sometimes  slightly 


SIGNS  OF  PRESSURE 


321 


moveable,  if  the  enlargement  is  not  sufficiently  great  to  in- 
volve the  mesentery  in  the  swelling. 

There  sometimes  appears  to  be  a  little  tenderness  on 
pressure,  but  the  tenderness  is  not  necessarily  a  sign  of  in- 
flammation of  the  diseased  glands,  for  it  is  found  in  cases 
where  no  trace  of  inflammation  is  discoverable  on  a  post- 
mortem examination. 

When  the  glands  reach  a  considerable  size  they  may 
press  upon  neighbouring  parts,  so  as  to  produce  secondary 
derangements.  Thus,  pressure  upon  the  nerves  may  cause 
cramps  in  the  legs.  Compression  of  the  large  venous 
trunks  may  give  rise  to  oedema  of  the  lower  limbs,  and 
dilatation  of  the  abdominal  veins.  If  this  venous  dilata- 
tion be  very  marked,  the  superficial  veins  being  seen  to 
ramify  upon  the  abdominal  wall  and  to  join  the  veins  of 
the  chest  wall,  enlargement  of  the  mesenteric  glands 
should  always  be  suspected  in  the  absence  of  chronic 
peritonitis,  or  disease  of  the  liver. 

Ascites  is  not  a  common  result  of  the  caseation  of  these 
glands,  and  is  rarely  produced  by  direct  pressure,  unless 
the  portal  vein  be  compressed  by  enlargement  of  the 
glands  occupying  the  hepatic  notch.  Sometimes,  however, 
we  find  cheesy  degeneration  of  the  mesenteric  glands  com- 
plicated by  tubercular  peritonitis.  In  these  cases  there  is 
a  rise  of  temperature,  with  increase  of  abdominal  tender- 
ness, and  colicky  pains.  The  belly  becomes  tense  from 
gaseous  distension  of  the  intestines  ;  and  indistinct  fluctua- 
tion is  often  felt  from  adhesion  of  the  bowels  one  to 
another,  with  the  addition  of  a  little  serous  effusion 
between  the  coils.  Vomiting  is  not  constant,  and  diarrhoea, 
if  previously  present,  is  not  interfered  with.  The  amount 
of  ascites  is  in  these  cases  not  very  great,  and  the  sym- 
ptoms of  peritonitis  generally  are  often  far  from  being  well 
marked. 

In  ordinary  cases  cheesy  mesenteric  glands  after  a  time 
diminish  in  size,  and  become  small  and  hard  by  absorp- 

21 


322  TUBERCULOSIS  OF  MESENTERIC  GLANDS 

tion  of  their  fluid  parts,  and  tlie  deposition  of  calcareous 
salts.  This  may  be  considered  the  natural  termination 
of  tabes  mesenterica.  It  is  rare  for  the  glands  to  soften, 
but  such  an  exceptional  result  of  the  degeneration  is 
occasionally  seen.  Adhesion  may  then  take  place  between 
the  gland  and  a  coil  of  intestine,  so  that  the  softened 
matter  is  evacuated  into  the  bowel. 

Diagnosis. — The  diagnosis  of  enlarged  glands  in  the 
mesentery  can  only  be  made  satisfactory  by  the  sense  of 
touch.  If  we  can  hold  the  mass  between  the  finger  and 
thumb,  proof  of  its  presence  is  indisputable,  and  this 
proof  is  the  only  one  which  leaves  no  doubt  upon  the 
mind.  Enlargement  of  the  belly  is  no  evidence  of  the 
glandular  disease,  for  flatulent  distension  is  in  children  a 
common  accompaniment  of  ill-health.  Wasting,  again, 
is  found  in  almost  all  forms  of  chronic  illness;  and 
diarrhoea  is  not  necessarily  connected  with  tuberculous 
abdominal  glands.  All  these  symptoms  may  be  present  in 
the  case,  but  they  are  not  characteristic  of  mesenteric 
disease,  and  we  should  not  be  justified  in  founding  a  dia- 
gnosis upon  them. 

If,  as  has  been  said,  the  superficial  veins  are  distinctly 
seen  to  ramify  on  the  abdominal  wall,  and  to  join  similar 
veins  on  the  thoracic  parietes,  glandular  disease  may  be 
suspected ;  but  nothing  more  than  suspicion  is  allowed  by 
such  evidence.  Any  interference  with  the  portal  circula- 
tion will  produce  the  same  result,  and  when  the  abdo- 
minal wall  is  tense  it  is  difficult  to  exclude  hepatic 
disease. 

Even  when  by  direct  exploration  the  existence  of  a 
tumour  in  the  belly  has  been  ascertained,  we  have  still  to 
satisfy  ourselves  that  the  tumour  is  formed  by  enlarged 
mesenteric  glands.  The  disease  may  be  simulated  by 
faecal  accumulation  in  the  colon,  or  by  caseous  masses 
attached  to  the  omentum. 

Fsecal  accumulations  are  much  more  superficial  than 


DIAGNOSIS 


323 


enlarged  glands,  and  are  also  distinguished  by  the  absence 
of  tenderness;  by  the  situation  of  the  tumour,  which 
usually  occupies  the  traverse  or  descending  colon  instead 
of  the  umbilical  region ;  and  by  the  shape  of  the  mass, 
which  is  elongated,  the  long  axis  being  in  the  direction  of 
the  long  axis  of  the  bowel  in  which  it  is  contained. 
Moreover,  the  masses  can  usually  be  indented  by  firm 
pressure  with  a  finger.  In  doubtful  cases  a  positive 
opinion  should  be  reserved  until  the  effect  upon  the  swell- 
ing of  a  good  injection  has  been  tried.  For  a  child  of 
four  years  old,  an  enema  of  a  pint  or  more  of  soap  and 
water,  or  thin  gruel,  containing  half  an  ounce  of  oil  of 
turpentine  and  four  ounces  of  olive  oil,  should  be  thrown 
up  the  bowel  by  a  good  syringe.  The  injection  should  be 
retained  for  a  few  minutes  by  firm  pressure  upon  the  anus, 
and  then  be  allowed  to  escape.  If  the  tumour  is  due  to 
faecal  accumulation,  a  quantity  of  pale,  brittle  lumps  will 
be  discharged  with  the  returning  fluid,  and  the  swelling 
previously  noticed  in  the  belly  will  be  found  to  have 
disappeared.  If  diseased  glands  are  the  cause  of  the 
tumour,  the  evacuation  of  gas  and  faecal  matter  will  only 
make  the  presence  of  the  enlargement  more  manifest,  by 
removing  the  tension  of  the  abdominal  wall,  and  allowing 
of  more  efficient  exploration  of  the  cavity  of  the  belly.  In 
these  cases  an  enema  of  sufficient  quantity  to  distend  the 
bowel  is  of  more  value  than  any  number  of  aperients.  It 
is  well,  also,  to  remember  that  faecal  accumulation  having 
once  occurred,  there  is  great  liability  to  a  second  collection 
of  the  same  kind ;  therefore  for  some  time  afterwards  a 
careful  watch  should  be  kept  over  the  condition  of  the 
bowels. 

Between  cheesy  masses  attached  to  the  omentum  and 
cheesy  mesenteric  glands  the  distinction  is  often  very 
difficult,  particularly  if  the  seat  of  the  tumour  happens 
to  be  the  umbilical  region.  When  their  seat  is  the  omen- 
tum the  masses  are  more  superficial,  are  less  nodular,  and 


324  TUBERCULOSIS  OP  MESENTERIC  GLANDS 

have  better  defined  edges  than  is  the  case  where  the 
glands  themselves  are  diseased.  They  are  usually  also 
more  freely  moveable. 

In  a  case  mentioned  by  MM.  Rilliet  and  Barthez,  a 
cancerous  pancreas  offered  some  resemblance  to  a  mass  of 
enlarged  glands,  but  was  distinguished  by,  amongst  other 
signs,  the  presence  of  vomiting,  jaundice,  and  abdominal 
pains. 

When  we  have  satisfied  ourselves  as  to  the  existence  of 
caseous  mesenteric  glands  it  is  important  to  ascertain  if 
this  be  the  sole  lesion  discoverable,  or  if  it  be  complicated 
by  intestinal  ulceration  or  other  abdominal  mischief. 
Elevation  of  temperature,  or  any  indications  of  marked 
interference  with  nutrition,  would  lead  us  to  suspect  the 
existence  of  some  complication.  The  most  common  of 
these  are  tubercular  peritonitis  and  intestinal  ulceration. 
In  the  case  of  the  former  we  find  usually  swelling,  pain 
and  tenderness  of  the  abdomen,  with  great  tension  of  the 
parietes  and  unequal  sense  of  resistance  on  pressure  of 
the  abdomen.  Often  there  is  an  obscure  sense  of  fluctu- 
ation. Ulceration  of  the  bowels  is  shown  by  local  ten- 
derness of  the  belly  with  some  tension  of  the  parietes, 
combined  with  the  discharge  of  offensive  dark  watery 
motions,  containing  a  deposit  of  flaky  matter,  and  mucus, 
with  small  black  clots  of  blood. 

Diarrhoea  is  not,  however,  present  in  every  case  of 
ulceration  of  the  bowels.  The  loose  frequent  stools  are 
not  dependent  upon  the  ulceration,  but  are  the  conse- 
quence of  the  catarrh  of  mucous  membrane  which 
commonly  accompanies  it.  This  is  apt  to  vary  greatly  in 
intensity ;  and  the  diarrhoea  may  be  better  or  worse,  or 
may  even  become  arrested  for  a  time,  without  the  breach 
of  surface  in  the  intestinal  mucous  membrane  having 
necessarily  healed.  Therefore,  even  if  there  be  no 
diarrhoea,  the  existence  of  fever  with  abdominal  tender- 
ness (peritonitis  being  of  course  excluded),  and  of  some 


PROONOSIS 


325 


colicky  pain  preceding  the  evacuations,  should  give  rise  to 
strong  suspicion  of  the  presence  of  intestinal  ulceration, 
especially  if  the  patient  be  subject  to  attacks  of  loose- 
ness in  the  bowels.  If,  in  addition,  there  be  evidence  of 
chronic  lung  disease,  the  frequency  with  which  tuberculous 
ulcers  of  the  alimentary  canal  complicate  cases  of  pul- 
monary consumption  must  not  be  forgotten. 

Prognosis. — The  serious  consequences  usually  associated 
with  mesenteric  disease  are  dependent,  not  upon  the 
glandular  enlargement,  but  upon  the  lesions  by  which  it 
is  apt  to  be  accompanied.  In  an  uncomplicated  case, 
apart  from  the  danger  which  is  common  to  tuberculous 
glands  in  general,  there  is  no  extraordinary  cause  of 
anxiety  in  caseous  degeneration  of  the  mesenteric  glands. 
Indeed,  on  account  of  their  slight  tendency  to  undergo 
softening,  disease  in  these  glands  is  perhaps  less  likely  to 
be  followed  by  ill  consequences  than  a  similar  affection  of 
any  other  glands  in  the  body.  In  rare  cases,  it  is  true, 
where  the  increase  in  size  is  unusually  great,  the  excep- 
tional dimensions  of  the  tumour  may  form  a  special  source 
of  danger ;  but  if  the  enlargement  is  moderate  and  is  the 
sole  lesion  discoverable,  and  the  temperature  of  the  child 
is  natural,  little  anxiety  need  be  excited,  for  so  long  as  the 
nutrition  of  the  patient  remains  good  there  is  every 
reason  to  hope  that  the  swelling  of  the  glands  may  sub- 
side. If,  however,  the  presence  of  wasting  with  fever 
indicates  the  existence  of  some  complication,  the  prog- 
nosis becomes  more  serious.  It  is  not  uncommon  for 
enlarged  mesenteric  glands  to  be  conjoined  with  ulcera- 
tion of  the  bowels  and  chronic  pulmonary  disease.  In 
these  cases  there  is  necessarily  very  great  danger,  and  the 
progress  of  the  case  must  be  watched  with  serious  appre- 
hension ;  but  the  danger  arises  from  the  condition  of  the 
lungs  and  bowels,  and  can  scarcely  be  said  to  be  aggra- 
vated by  the  glandular  enlargement.  Tuberculous  peri- 
tonitis is  not  necessarily  fatal  if  the  bowels  are  intact. 


326  TUBERCULOSIS  OF  MESENTERIC  GLANDS 

but  if  intestinal  ulceration  complicates  the  peritonitis,  the 
patient  generally  dies. 

Treatment. — On  account  of  the  readiness  with  which 
the  lymphatic  glands,  both  internal  and  external,  become 
enlarged  in  tuberculous  children  it  is  of  great  importance 
to  remove  as  quickly  as  possible  any  local  irritations,  the 
continuance  of  which  would  lead  to  the  glandular  disease. 
All  purulent  discharges,  skin  eruptions,  and  ulcerations  of 
the  skin  and  mucous  membrane  must  therefore  receive 
prompt  attention.  "  Little  "  colds  must  not  be  neglected, 
as  disease  of  the  bronchial  glands  is  encouraged  by  pulmo- 
nary irritation  ;  and  the  possibility  of  caseous  enlargement 
of  the  glands  of  the  mesentery  is  an  additional  reason  for 
keeping  a  careful  watch  over  the  condition  of  the  stomach 
and  bowels. 

In  all  cases  where  there  is  cheesy  degeneration  of  glands, 
wherever  these  may  be  seated,  prompt  measures  must  be 
taken  to  improve  the  general  health  of  the  child.  To 
effect  this  object  the  dietary  should  be  constructed  upon 
the  principle  which  has  already  been  so  strongly  insisted 
on  in  these  pages,  that,  viz.,  of  suj^plying  a  sufficient 
amount  of  nourishment  to  the  body  without  undue  labour 
to  the  digestive  organs.  This  is  best  done  by  depending 
largely  upon  meat,  eggs,  fish,  and  milk,  and  carefully 
avoiding  excess  of  farinaceous  or  other  fermentable 
articles,  such  as  would  be  likely  to  cause  acidity  of  the 
stomach  and  indigestion. 

Change  of  air  is  of  great  importance.  As  soon  as  pos- 
sible the  child  should  be  removed  to  some  bracing  spot, 
where  the  air  is  dry  and  the  soil  porous.  An  inland  place 
is  to  be  preferred  to  the  sea- side.  Here  the  patient  may 
pass  his  time  out  of  doors  whenever  the  weather  permits  ; 
and  at  night,  if  the  season  be  temperate,  and  the  air  not 
too  damp,  his  window  can  be  open  at  the  top,  so  as  to 
insure  fl:ee  ventilation  of  the  sleeping-room.  For  some 
directions  upon  the  important  subject  of  diet  and  general 


SPECIAL  TREATMENT 


327 


hygiene  the  reader  is  referred  to  the  chapter  on  chronic 
pulmonary  phthisis. 

Amongst  the  means  for  improving  the  general  health, 
cold  bathing  must  not  be  forgotten.  Cold  douches  have 
been  found  of  special  service  in  the  treatment  of  caseous 
lymphatic  glands ;  and  if  proper  precautions  be  taken, 
there  is  little  danger  of  a  chill,  however  apparently 
delicate  the  child  may  be.  The  best  way  of  employing 
the  cold  bath  is  the  following : — The  child  is  made  to  sit 
with  his  feet  and  lower  part  of  his  body  in  water  of  the 
temperature  of  100'^  to  101°,  and  is  rapidly  sponged  with 
the  hot  water  for  one  minute.  A  basin  of  water  at  75°  is 
then  emptied  over  his  shoulders  as  he  sits  in  the  bath,  and 
he  is  quickly  dried  and  dressed.  The  douche  water  may 
be  made  more  stimulating  by  the  addition  of  a  packet  of 

Brill's  sea  salt."  Although  the  bath  is  taken  before 
breakfast  the  child  must  not  be  fasting.  All  children, 
especially  weakly  ones,  should  have  a  slice  of  bread  or  a 
dry  biscuit,  and,  if  possible,  a  drink  of  milk,  on  waking  in 
the  morning. 

With  regard  to  special  treatment: — If  the  gland  be 
external,  and  there  be  no  signs  of  softening  or  suppuration, 
the  liniment  of  iodine  may  be  painted  on  the  swelling 
every  night ;  or  the  oleate  of  mercury  ointment  may  be 
made  use  of.  This  latter  application  should  be  rather 
weak  (five  per  cent.),  and  should  be  smeared  on  the  part, 
not  rubbed  in.  It  can  be  used  twice  a  day  for  five  days, 
then  at  night  only,  and  afterwards  every  other  day. 
Iodine  ointment  is  sometimes  very  successful  in  removing 
caseous  glands,  but  the  application  should  be  employed 
with  caution,  as  it  may  produce  sloughing.  External 
treatment  must  be  supplemented  by  sea  air  and  the 
internal  administration  of  iron  and  arsenic  in  full  doses. 

The  above  measures  are  not  set  forth  as  the  best  method 
of  treating  chronic  tuberculous  glands,  but  they  often 
represent  all  we  can  succeed  in  doing,  for  it  is  difiicult  to 


328  TUBERCULOSIS  OF  MESENTERIC  GLANDS 

overcome  the  natural  objections  of  parents  to  an  operation 
in  cases  where  the  symptoms  are  not  pressing  and  the 
danger  of  ill  consequences  seems  to  be  remote.  Still,  there 
is  no  doubt  that  removal  by  surgical  procedure  of  the 
diseased  organs  is  the  quickest  and  most  certain  way  to 
obtain  a  cure.  If  the  affected  glands  are  few  and  mode- 
rate in  size  we  may  venture  to  sanction  delay ;  but  this 
should  be  done  on  the  understanding  that  the  patient 
shall  be  sent  at  once  to  a  bracing  seaside  j^lace,  and  put 
into  the  best  conditions  for  recovery.  If,  however,  many 
glands  are  diseased,  and  the  patient  is  a  delicate  member 
of  a  family  in  which  others  have  already  suffered  from 
tuberculosis,  further  delay  would  aggravate  the  risk,  and 
we  ought  not  to  hesitate  to  urge  the  necessity  of  removal. 
This  is  the  more  important  if  there  are  signs  of  softening 
or  suppuration.  The  danger  of  general  infection  of  the 
system  then  becomes  pressing,  and  an  operation  is  impera- 
tive. 

When  the  bronchial  glands  are  found  to  be  enlarged 
every  care  should  be  taken  to  protect  the  patient  against 
pulmonary  catarrhs  and  other  forms  of  chest  irritation,  so 
as  to  avoid  any  aggravation  of  the  already  existing  evil. 
The  chest  should  be  carefully  protected  by  thick  flannel 
worn  next  to  the  skin.  Children  of  both  sexes  should  be 
provided  with  a  closely  fitting  flannel  under- garment, 
made  to  reach  up  to  the  neck.  Thus  guarded,  the  patient 
can  pass  a  large  portion  of  the  day  out  of  doors ;  and  the 
drier  the  air  and  more  porous  the  soil  of  the  spot  in  which 
he  is  living  the  better  for  his  chances  of  improvement. 
The  diet  must  be  regulated  with  care,  as  already  directed, 
and  the  cold  bath,  used  with  all  needful  precautions,  must 
not  be  forgotten.  Cod-liver  oil  is  of  great  service  in 
these  cases,  and  the  popular  remedy — iodide  of  iron — has 
no  doubt  a  certain  value.  This  is  best  given  made  into  a 
draught  by  combining  iodide  of  potassium  with  tartrate  of 
iron  in  distilled  water,  the  syrup  of  the  iodide,  which  is 


TREATMENT • 


329 


the  more  favourite  form  for  its  administration,  being  apt 
to  ferment  in  the  stomach  and  cause  acidity.  Instead  of 
an  iodide,  iodine  itself  may  be  given,  and  the  internal 
administration  of  tincture  of  iodine  in  small  doses  (two  or 
three  drops  freely  diluted)  is  preferred  by  some  practi- 
tioners. Blisters,  so  often  recommended  in  these  cases, 
appear  to  be  attended  by  but  little  benefit.  The  local 
application  of  iodine,  on  the  contrary,  is  often  very  useful, 
and  frictions  with  iodine  ointment  over  the  upper  part  of 
the  chest,  or  painting  with  the  liniment  in  the  same  situa- 
tion, should  never  be  omitted,  especially  when  the  glands 
are  of  considerable  size. 

In  the  severe  asthmatic  attacks  little  is  to  be  done  by 
antispasmodics,  and  the  harassing  cough  is  not  to  be  con- 
trolled by  narcotics.  Energetic  counter-irritation  with 
iodine  preparations  has,  however,  sometimes  seemed  to  be 
of  service. 

When  the  glands  of  the  mesentery  are  diseased  our  first 
care  should  be  to  remove  any  existing  irritation  of  the 
intestinal  canal.  Where  there  is  diarrhoea  the  motions 
should  be  inspected,  and  if  the  stools  are  found  to  consist 
of  putrid- smelling  dirty  water,  with  a  thick  sediment  con- 
taining shreddy  matter  mixed  up  with  small  black  clots  of 
blood,  there  is  little  doubt  that  the  bowels  are  ulcerated. 
In  these  cases  suitable  treatment  must  be  adopted,  as 
recommended  in  the  chapter  on  chronic  diarrhoea.  Small 
enemata  of  thin  warm  starch  containing  a  few  drops  of 
laudanum  are  very  useful.  If  tubercular  peritonitis  occur, 
hot  linseed-meal  poultices  applied  to  the  belly,  and  opium 
given  cautiously  by  the  mouth,  form  the  best  remedies. 

In  cases  where  the  glandular  enlargement  is  uncompli- 
cated, fresh  air,  good  diet,  and  cod-liver  oil,  as  before 
directed,  will  do  all  that  is  necessary.  In  these  cases  a 
broad  flannel  bandage  applied  tightly  to  the  belly,  and 
worn  well  down  over  the  hips,  is  an  indispensable  part  of 
the  treatment. 


CHAPTER  XII 


DIET  OF  CHILDREN  IN  HEALTH  AND  DISEASE 

0]^^  account  of  the  importance  of  the  subject  of  diet  in 
relation  to  children,  both  in  health  and  disease,  the 
maintenance  of  their  health,  and  the  treatment  of  their 
several  disorders  being  mainly  dependent  upon  a  proper 
regulation  of  their  food,  it  has  been  thought  advisable  to 
devote  a  chapter  especially  to  this  subject. 

Directions  upon  this  matter,  to  be  of  any  service  at  all, 
must  be  plain,  minute,  and  exhaustive,  l^othing  should 
be  left  to  the  discretion  of  the  attendants.  The  articles 
of  food,  the  quantity  to  be  given,  the  hours  at  which  the 
meals  are  to  be  taken,  and,  when  necessary,  the  exact 
method  in  which  the  food  is  to  be  prepared,  should  be 
all  accurately  stated  and  written  down,  or  mistakes  will 
almost  certainly  be  committed. 

In  the  following  pages  will  be  found  dietaries,  carefully 
arranged  and  tabulated,  suitable  to  infants  and  children 
of  various  ages,  both  in  health  and  disease.  It  should  be 
stated,  however,  that  the  quantities  given  below  are  not 
intended  to  be  invariable.  It  would  be  impossible  to  lay 
down  rules  which  would  be  found  suitable  to  all  children. 
Some  require  and  can  digest  much  more  than  others ;  the 
quantities,  therefore,  must  be  adapted  in  each  particular 
case  to  the  needs  and  capabilities  of  the  child.  The 
amounts  of  farinaceous  food  ordered  can,  however,  seldom 
be  exceeded  with  safety. 


FROM  BIRTH  TO  SIX  MONTHS  OLD 


331 


Diet  in  Health. 
1.  PROM  BIRTH  TO  SIX  MONTHS  OLD. 
Diet  1. 

If  the  child  be  suckled,  and  the  breast-milk  be  found 
in  all  respects  suitable, — 

No  other  food  should  be  given. 

The  child  should  take  the  breast  every  two  hours  for 
the  first  six  weeks  ;  afterwards,  every  three  hours,  except 
between  11  p.m.  and  5  or  6  a.m. 

In  cases  where  the  secretion  of  milk  is  slow  to  be  estab- 
lished, and  the  quantity  drawn  is  insufficient  to  supply 
the  wants  of  the  infant,  the  following  food  may  be  given 
as  an  addition  to  the  breast-milk,  until  the  secretion 
becomes  sufficiently  abundant : — 

One  tablespoonful  of  fresh  cream. 
Two  tablespoonfuls  of  whey.^ 
Two  tablespoonfuls  of  hot  water. 
Half  a  teaspoonful  of  sugar  of  milk. 

This  mixture  must  be  taken  from  a  feeding-bottle. 

Or,  we  may  make  use  of  condensed  milk  for  a  month  or 
two,  diluted  with  eight  or  nine  times  its  bulk  of  water. 
Condensed  milk  should  not,  however,  be  depended  upon 
as  the  sole  food  of  the  infant  after  the  end  of  the  third 
month. 

Diet  2. 

If  the  infant  be  brought  up  by  hand : — 

For  the  first  few  days  the  mixture  of  whey,  cream,  and 

*  Fresh  whey  is  supplied  in  London  to  order  by  the  Aylesbury  Milk 
Company ;  but  it  is  better  to  make  the  whey  at  home  by  means  of 
"Benger's  curdling  fluid,"  which  makes  a  beautiful  whey  very  quickly. 
Full  directions  are  given  on  the  bottles. 


332  DIET  IN  HEALTH 

hot  water  (see  above)  may  be  given,  but  before  the  end  of 
the  week  we  should  make  a  trial  of  cow's  milk  boiled  in  a 
water-bath  or  sterilised. 

Milk,  one  tablespoonful. 

Fresh  barley-water,  two  tablespoonfuls. 

Water,  one  tablespoonful. 

Cream,  a  teaspoonful. 

Sugar  of  milk,  a  flat  teaspoonful. 

Bicarbonate  of  soda,  a  small  pinch. 

Or, 

Milk,  one  tablespoonful. 
Lime  water,  one  tablespoonful. 
Water,  two  tablespoonfuls. 
Cream,  a  teaspoonful. 
Sugar  of  milk,  a  flat  teaspoonful. 

The  quantities  of  these  ingredients  may  be  varied  from 
day  to  day  or  even  from  meal  to  meal,  according  to  the 
state  of  the  child's  digestion.  Probably  in  a  very  few 
days  the  proportion  of  milk  will  have  to  be  increased ;  but 
at  first  it  is  better  to  give  too  little  than  too  much ;  and  if 
the  stools  contain  lumps  of  curd  and  the  child  cry  with 
colicky  pains,  the  milk  must  be  further  diluted  so  as  to 
reduce  the  percentage  of  proteids.  If  there  be  vomiting 
or  a  relaxed  state  of  the  bowels,  we  should  lessen  the 
quantity  of  cream.  In  any  case  as  the  child  grows  the 
allowance  of  milk  in  his  meals  must  be  increased,  and  by 
the  end  of  the  second  month  he  should  be  taking  a  third 
part  of  milk,  or  even  more  if  we  find  he  can  digest  it. 
Our  object  is  to  give  the  child  as  much  food  as  his  system 
requires,  but  no  more.  It  is  important  not  to  stint  the 
infant,  or  he  will  fret  day  and  night  from  hunger.  On 
the  other  hand,  we  must  be  just  as  careful  not  to  overload 
him  with  food ;  still,  if  we  proceed  step  by  step,  and  the 
child  show  no  sign  of  indigestion,  we  may  progressively 


FROM  BIRTH  TO  SIX  MONTHS  OLD 


333 


increase  his  proportion  of  milk  without  fear  of  upsetting 
his  stomach. 

In  the  case  of  most  hand-fed  children  it  is  found  useful 
to  introduce  a  certain  variety  into  their  diet,  for  by  this 
means  digestion  is  undoubtedly  encouraged.  With  this 
object  extract  of  malt  may  be  used  as  a  sweetener  in 
alternate  meals,  or  the  following  may  be  given  in  rotation 
with  the  others.  It  sometimes  happens,  indeed,  that  the 
infant  can  only  be  efficiently  nourished  on  the  condition 
that  no  two  meals  in  the  same  day  are  composed  of 
exactly  the  same  materials. 

Milk  and  water  with  gelatine  (see  p.  38). 

Mellin's  food,  one  teaspoonful. 
Milk,  one  part. 

Fresh  barley-water,  two  parts. 
Cream,  a  teaspoonful. 

Peptonised  milk  (see  p.  46). 

Allen  and  Hanbury's  No.  1  food. 

Diet  3. 

If  the  infant  be  partially  suckled,  the  breast-milk  being 
poor  and  scanty, — 

The  breast  must  be  given  only  twice  a  day. 

For  the  other  meals  the  child  must  be  fed  as  directed  in 
Diet  2. 

All  these  foods  should  be  sweetened  to  taste  with  white 
sugar  or  sugar  of  milk,  and  if  poor  in  fat  may  be  fortified 
by  a  spoonful  of  cream. 

N.B. — It  is  important  that  the  materials  used  should 
be  perfectly  fresh.  Stale  cream,  whey,  or  barley-water  is 
sure  to  disagree. 


334 


DIET  IN  HEALTH 


2.  FROM  SIX  TO  TWELVE  MONTHS  OLD. 

Five  meals  in  the  day. 
Diet  4. 

First  meal,  7  a.m. 

One  teaspoonful  of  baked  flour  carefully  prepared, 
with  a  teacupful  of  milk  and  Sweetened  with 
a  small  teaspoonful  of  extract  of  malt.  (See 
page  49.) 

Second  meal,  10.30  a.m.  ;  and 

Third  meal,  2  p.m. 

A  tablespoonful  of  Mellin's  food,  in  a  breakfast- 
cupful  of  milk  thickened  with  a  teaspoonful  of 
gelatine. 

Fourth  meal,  5.30  p.m. 
Same  as  the  first. 

Fifth  meal,  11  p.m. 

Same  as  the  third. 

For  the  second  meal,  twice  a  week,  may  be  given  the 
yolk  of  one  egg,  beaten  up  with  a  teacupful  of  milk. 

The  method  of  preparing  baked  flour  is  given  on  page 
49.  Chapman's  entire  wheaten  flour  should  always  be 
used.  It  is  much  to  be  preferred  for  children  to  the 
ordinary  wheaten  flour,  containing  as  it  does  the  phos- 
phates of  the  wheat,  and  the  cerealin,  a  peculiar  body 
which  changes  starchy  matters  into  dextrine.  If  there  be 
constipation,  a  teaspoonful  of  fine  oatmeal  can  be  used 
instead. 

Sometimes  in  the  case  of  infants  of  nine  or  ten  months 
old  Mellin's  food  with  milk  alone  does  not  seem  suffi- 
ciently satisfying.  In  these  cases  it  is  advisable  to  add 
to  the  meal  a  teaspoonful  of  baked  flour.    The  flour  is 


FROM  SIX  TO   TWELVE  MONTHS  OLD 


335 


first  rubbed  up  with  the  milk,  as  directed  on  page  49, 
and  the  Mellin's  food  is  added  afterwards. 

Diet  5. 

For  a  child  about  ten  months  old. 

First  meal,  7  a.m. 

A  tablespoonful  of  Mellin's  food. 

A  teaspoonful  of  Chapman's  flour  (bated). 

A  breakfast-cupful  of  new  milk. 

Second  meal,  10.30  a.m. 

A  tablespoonful  of  pearl  barley  jelly  ^  dissolved 
in  a  breakfast-cupful  of  warm  milk,  and 
sweetened  with  white  sugar. 

Third  w.eal,  2  p.m. 

The  yolk  of  one  egg  beaten  up  in  a  teacupful  of 
milk,  and  sweetened  with  white  sugar. 

Fourth  meal,  5.30  p.m. 
Same  as  the  second. 

Fifth  meal,  11  p.m. 

Same  as  the  first. 

Diet  6. 

To  alternate  with  the  precediiig. 

First  meal,  7  a.m. 

Half  a  teaspoonful  of  cocoatina,t  boiled  for  one 
minute  in  a  breakfast-cupful  of  milk. 

*  Put  two  tablespoonfuls  of  washed  pearl  barley  into  a  saucepan, 
with  a  pint  and  a  half  of  water,  and  simmer  down  to  a  pint.  Strain 
away  the  barley  and  allow  the  liquid  to  set  into  a  jelly. 

t  In  cocoatina  a  considerable  portion  of  the  fatty  matter  is  removed. 
It  is,  therefore,  more  digestible  than  the  ordinary  cocoas,  and  far  better 
adapted  for  an  infant's  diet.  A  dessertspoonful  of  Mellin's  food  may 
be  added  to  this  meal  if  thought  desirable. 


336 


DIET  IN  HEALTH 


Second  meal,  10.30  a.m. 

A  breakfast-cupful  of  milk  alkalinised,  if  necessary, 
by  fifteen  drops  of  the  saccharated  solution  of 
lime,  and  thickened  with  a  teaspoonful  of  isin- 
glass or  gelatine  and  sweetened. 

Third  meal,  2  p.m. 

A  teacupf  ul  of  beef  tea  *  (half  a  pound  of  meat  to 

the  pint)  thickened  with  barley  and  strained. 
A  rusk. 

Fourth  meal,  5.30  p.m. 

A  tablespoonful  of  pearl  barley  jelly,  dissolved  in  a 
breakfast-cupful  of  milk  and  sweetened. 

Fifth  mealy  11  p.m. 

Same  as  the  second. 

It  is  advisable,  as  a  rule,  to  avoid  giving  intermediate 
meals,  and  therefore  the  meals  should  be  made  sufficiently 
large  to  satisfy  all  reasonable  demands. 

If  the  child  requires  food  before  7  a.m.,  on  waking  from 
sleep,  a  little  milk  may  be  given  him. 

A  healthy  child,  between  ten  and  twelve  months  old, 
will  require  a  pint  and  a  half  of  milk  in  the  twenty-four 
hours. 

*  Beef  tea  is  to  be  made  in  the  following  way : — Put  half  a  pound 
(or  a  pound,  according  to  the  strength  required)  of  rump  steak,  cut 
up  into  small  pieces,  into  a  covered  copper  saucepan,  with  one  pint  of 
cold  water.  Let  this  stand  by  the  side  of  the  fire  for  four  or  five 
hours,  and  let  it  then  simmer  gently  for  two  hours.  Skim  well  and 
serve.  The  meat  used  should  be  as  fresh  as  possible — the  fresher  the 
better — and  should  be  cleared  beforehand  of  all  fat  or  gristle.  If  this 
precaution  be  neglected,  a  greasy  taste  is  given  to  the  beef  tea  which 
cannot  be  afterwards  removed  by  skimming.  The  saucepan  used 
should  be  made  of  copper  or  tin.  Iron  saucepans  should  not  be  used 
unless  enamelled.  In  re-warming  beef  tea  which  has  been  left  to  cool 
care  must  be  taken  to  warm  the  tea  up  to  the  point  at  which  it  is  to 
be  served,  and  no  higher.    It  should  on  no  account  be  allowed  to  boil. 


FROM  TWELVE  TO  EIGHTEEN  MONTHS  OLD.  337 


3.  FROM  TWELVE  TO  EIGHTEEN  MONTHS. 
Diet  7. 

First  meal,  7.30  a.m. 

A  rusk,  or  a  slice  of  stale  bread,  well  soaked  in  a 
breakfast-cupful  of  new  milk. 

Second  meal,  1 1  a.m. 

A  drink  of  milk ;  a  plain  biscuit  or  slice  of  thin 
bread-and-butter. 

Third  meal,  1.30  p.m. 

A  teacupful  of  good  beef  tea  (a  pound  of  meat  to 

the  pint)  or  of  beef  gravy,  with  rusk. 
A  good  tablespoonful  of  light  farinaceous  pud- 
ding. 

Fourth  meal,  5.30  p.m. 
Same  as  the  first. 

Fifth  meal,  11  p.m.  (if  required). 
A  drink  of  milk. 

Diet  8. 

(To  alternate  with  the  preceding.) 

First  meal,  7.30  a.m. 

The  yolk  of  a  lightly  boiled  egg. 
A  slice  of  thin  bread-and-butter. 
A  cupful  of  new  milk. 

Second  meal,  11  a.m. 
A  drink  of  milk. 
A  slice  of  thin  bread-and-butter. 

Third  meal,  1.30  p.m. 

A  mealy  potato,  well  mashed  with  a  spoon,  moist- 
ened with  two  tablespoonfuls  of  good  beef 
gravy. 
A  cupful  of  new  milk. 

22 


338 


DIET  IN  HEALTH 


Fourth  meal,  5.30  p.m. 

A  rusk  or  slice  of  stale  bread,  well  soaked  in  a 
breakfast-cupful  of  milk. 

Fifth  meal,  11  p.m.  (if  required). 
A  drink  of  milk. 

The  fifth  meal,  at  11  p.m.,  should  never  be  given  un- 
necessarily. The  sooner  a  child  becomes  accustomed  to 
sleep  all  night  without  food  the  better.  When,  however, 
he  wakes  in  the  morning,  refreshed  by  his  night's  rest,  he 
should  never  be  allowed  to  remain  fasting  for  an  hour  or 
more  until  his  breakfast  is  prepared.  A  drink  of  milk 
or  a  thin  slice  of  bread-and-butter  should  be  given  at 
once. 

Some  children  will  take  larger  quantities  than  others  at 
one  meal ;  but  if  the  meals  are  made  very  large  their 
number  must  be  reduced  in  proportion.  Many  children 
between  twelve  and  eighteen  months  old  will  be  found  to  do 
well  upon  only  three  meals  a  day,  as  in  the  following :  — 

Diet  9. 

First  meal,  8  a.m. 

One  teaspoonful  of  baked  flour. 
One  teaspoonful  of  fine  oatmeal. 
Three-quarters  of  a  pint  of  fresh  milk. 
A  little  white  sugar. 

Second  meal,  1  p.m. 

The  same,  with  the  addition  of  the  yolk  of  one  egg. 

Third  meal,  5  p.m. 
Same  as  the  first. 

In  this  diet  the  baked  flour  and  the  oatmeal  are  first 
beaten  up  till  smooth,  with  four  tablespoonfuls  of  cold 
water,  and  are  then  boiled.  The  milk  and  sugar  are  then 
added,  and  the  mixture  is  boiled  till  it  thickens. 


FROM  EIGHTEEN  MONTHS  TO  TWO  YEARS  OLD  339 


For  the  second  meal  the  yolk  of  egg  is  stirred  up  in  the 
saucepan  and  boiled  with  the  rest. 

If  the  child  requires  anything  early  in  the  morning,  or 
at  11  P.M.,  he  may  take  a  drink  of  milk,  or  a  thin  slice  of 
bread-and-butter. 

A  healthy  child  of  a  year  to  eighteen  months  old  will 
usually  take  from  a  pint  and  a  half  to  two  pints  of  milk 
in  the  four-and-twenty  hours. 

4.  FROM  EIGHTEEN  MONTHS  TO  TWO  YEARS  OLD. 
Diet  10. 

First  meal,  7.30  a.m. 

A  breakfast- cupful  of  new  milk. 
A  rusk,  or  half  a  slice  of  bread  soaked  in  the 
liquid  fat  of  hot  fried  bacon. 

Second  meal,  1 1  a.m. 

A  cup  of  milk  and  a  biscuit. 

Third  meal,  1.30  p.m. 

Underdone  roast  mutton,  pounded  in  a  warm  mortar, 

a  good  tablespoonful. 
One  well-mashed  potato  moistened  with  two  or  three 

tablespoonfuls  of  gravy. 
For  drink,  filtered  water  or  toast- water. 

Fourth  meal,  5.30  p.m. 

A  breakfast- cupful  of  milk. 
Thin  bread-and-butter. 

After  the  age  of  eighteen  months  it  is  well  to  omit  the 
meal  at  11  p.m.  A  healthy  child  of  eighteen  months  old 
should  sleep  from  6  p.m.  to  6  a.m.  without  waking. 


340 


DIET  IN  DISEASE 


Diet  11. 

(i^or  a  child  of  the  same  age.) 

First  meal,  7.30  a.m. 

A  breakfast-ciipful  of  new  milk. 
The  lightly  boiled  yolk  of  one  egg. 
Thin  bread-and-butter. 

Second  meal,  11  a.m. 
A  cup  of  milk. 

Third  meal,  1.30  p.m. 

A  breakfast-cupful  of  beef  tea  (a  pound  of  meat  to 
the  pint),  containing  a  few  well-boiled  aspara- 
gus heads  when  in  season,  or  a  little  thoroughly 
stewed  flower  of  broccoli. 

A  good  tablespoonful  of  plain  custard  pudding. 

Fourth  meal,  5  30  p.m. 

A  breakfast-cupful  of  milk. 
Bread-and-butter. 

These  diets  can  be  given  on  alternate  days 
Between  the  ages  of  two  and  three  years  the  same  diets 
may  be  continued.    Meat  can,  however,  be  given  every 
day,  and  a  little  well- stewed  fruit  may  be  occasionally 
added . 

The  morning  and  evening  meals  should  always  consist 
principally  of  milk. 

Diet  in  Disease. 
DIET  IN  INFANTILE  ATROPHY. 

(For  a  child  of  two  or  three  months  old,  brought  up  by  hand, 
weakly  and  emaciated,  in  whom,  milh  with  lime-water 


DIET    IN  INFANTILE  ATROPHY 


341 


excites  griping  and  flatulence,  with  occasional  attacks  of 
vomiting  and  purging. ) 

In  these  cases  special  attention  must  be  paid  to  the 
cleanliness  of  the  feeding-bottle.  It  is  important,  also, 
that  meals  consisting  of  milk  or  other  fermentable  matter 
be  prepared  in  small  quantities  as  they  are  wanted — to 
avoid  fermentation. 

We  can  often  succeed  in  rendering  the  milk  and  lime- 
water  digestible  by  adding  an  aromatic — such  as  a  tea- 
spoonful  of  cinnamon- water — to  the  food. 

If  this  do  not  succeed,  one  of  the  following  diets  can  be 
tried  : 

Diet  12. 

The  child  to  be  fed  every  two  or  three  hours  from  a 
feeding-bottle  with  the  following,  in  alternate  meals : 

1.  One  teaspoonful  of  Mellin's  food  for  infants  dissolved 

in  a  teacupful  of  new  milk  and  barley-water  (equal 
parts),  with  the  addition  of  one  teaspoonful  of 
cinnamon  or  dill  water. 

2.  Two  teaspoonfuls  of  Mellin's  food  dissolved  in  a  tea- 

cupful  of  fresh  whey  and  barley-water  (equal  parts) . 
Bovinine,  ten  drops. 

If  the  amount  of  milk  giveil  above  cannot  be  digested, 
as  often  happens,  the  proportion  of  barley-water  used  to 
dilute  the  milk  may  be  increased  to  two-thirds  ;  or  in  some 
of  the  meals  the  milk  may  be  altogether  omitted.  Instead, 
we  may  use  barley-water,  whey,  or  equal  proportions  of 
barley-water  and  weak  veal  or  chicken  broth,  in  which  the 
Mellin's  food  can  be  dissolved. 

In  the  place  of  ordinary  milk  we  may  use  strippings  " 
(see  page  45),  or  ass's  or  goat's  milk. 

In  the  above  diets  the  quantities  given  at  each  time  of 
feeding  must  be  proportioned  rather  to  the  strength  of  the 


342 


DIET  IN  DISEASE 


child  than  to  his  age.  The  more  weakly  the  infant,  the 
smaller  and  more  frequent  should  be  the  meals. 

In  cases  where  the  weakness  and  emaciation  are  great, 
the  child,  for  a  few  days,  should  be  fed  solely  upon  white 
wine  whey.  Afterwards,  when  the  strength  has  begun  to 
return,  the  wine  whey  may  be  given  in  alternate  meals  with 
peptonised  milk. 

Diet  13. 

White  wine  whey  (see  page  113). 
Peptonised  milk  (see  page  46). 

These  foods  to  be  given  alternately  in  such  quantities  as 
the  infant  is  found  to  digest  without  difficulty.  It  is  best 
to  begin  with  a  tablespoonful  every  half -hour;  but  this 
quantity  will  soon  have  to  be  increased.  As  the  meals  get 
larger  the  intervals  between  them  must  be  lengthened.  If 
cow's  milk,  however  prepared,  causes  indigestion  and  flatu- 
lence, a  desiccated  milk  food  will  often  agree  with  the 
stomach.  In  that  case  one  of  Allen  and  Hanbury's  foods 
(No.  1  or  No.  2)  may  be  substituted  in  this  diet  for  the 
peptonised  milk. 


DIET  IN  CHRONIC  DIARRHCEA. 

{For  a  child  ten  or  twelve  months  old,  who  can  hear  milk; 
purging  not  very  severe.) 

Diet  14. 

A  teaspoonful  of  Mellin's  food'  for  infants  every  three 
hours,  dissolved  alternately  in  milk  and  barley-water 
(equal  parts),  and  in  equal  parts  of  weak  veal  broth  and 
barley-water. 

If  no  milk  at  all  can  be  digested,  a  good  diet  is  the 
following  : 


DIET  IN  CHRONIC  DIAREHCEA 


343 


Diet  15. 

First  meal,  7  a.m. 

One  tablespoonful  of  Mellin's  food  for  infants,  dis- 
solyed  in  a  teacupful  of  veal  broth  and  barlej- 
water  (equal  parts). 

Second  meal,  11  a.m. 

One  dessertspoonful  of  cream  in  a  teacupful  of 
fresh  whey. 

Third  meal,  2  p.m. 

The  unboiled  yolk  of  one  egg  beaten  up  with  fifteen 
drops  of  brandy ;  a  tablespoonful  of  cinnamon 
water ;  and  a  little  white  sugar. 

Fourth  meal,  5  p.m. 

Four  ounces  of  veal  broth  (a  pound  to  the  pint) 
thickened  with  pearl  barley  and  strained. 

Fifth  meal,  11  p.m. 
Same  as  the  first. 

After  a  week  or  ten  days  a  little  milk  can  be  introduced 
into  the  diet,  beginning  cautiously,  and  only  once  in  the 
day.  Thus,  for  the  first  meal,  milk  may  be  substituted  for 
the  veal  broth,  and  be  added  to  the  barley-water  and 
Mellin's  food.  If  this  be  found  to  agree,  the  same  change 
may  be  made  in  the  fifth  meal. 

Another,  consisting  partially  of  milk,  for  a  child  of 
twelve  months  old : 

Diet  16. 

First  meal,  7  a.m. 

One  teaspoonful  of  cocoatina  boiled  for  one  minute 
with  a  teacupful  of  milk. 
Second  meal,  10  a.m. 

A  teacupful  of  veal  broth  (a  pound  to  the  pint) 
thickened  with  barley  and  strained. 


344  DIET  IN  DISEASE 

Third  meal,  2  p.m. 

A  teacupful  of  milk  alkalinised  with  fifteen  drops 
of  saccharated  solution  of  lime. 

Fourth  meal,  5  or  6  p.m. 

The  yolk  of  one  egg  beaten  up  with  brandy  and 
cinnamon- water,  as  in  Diet  15  ;  or  beaten  up 
with  a  teacupful  of  veal  broth  and  barley- 
water  (equal  parts). 

Fifth  meal,  11  p.m. 

One  tablespoonful  of  Mellin's  food  for  infants  dis- 
solved in  a  teacupful  of  warm  milk. 

If  the  child  be  much  reduced  by  the  purging,  the  diet 
should  be  simpler  in  character,  and  the  meals  should  be 
smaller,  more  frequently  repeated,  as  in  the  following  : — 


Diet  17. 

(For  a  weakly  child  of  twelve  months  old.) 

First  meal,  7  a.m. 

Four  ounces  of  peptonised  milk. 

Seco7id  meal,  9.30  a.m. 

Four  ounces  of  veal  broth  (half  a  pound  to  the 
pint)  thickened  with  barley  and  strained. 

Third  meal,  noon. 

A  tablespoonful  of  pearl  barley  jelly,  dissolved  in 
four  ounces  of  whey. 

Fourth  meal,  2.30  p.m. 

Four  ounces  of  milk  and  lime-water  (equal  parts), 
with  a  teaspoonful  of  cinnamon-water. 
Fifth  meal,  5  p.m. 

'  Two  teaspoonfuls  of  Mellin's  food  for  infants  dis- 
solved in  four  ounces  of  barley-water. 
Bovinine,  ten  drops. 


DIET  IN  CHRONIC  VOMITING 


345 


Sixth  meal,  9  p.m. 

Same  as  the  second. 
During  the  night  whey  or  barley-water  may  be  given, 
or  one  of  the  desiccated  milk  foods. 

If  the  purging  be  very  severe,  all  regular  meals  must 
be  discontinued.  Any  of  the  above  varieties  of  liquid 
food  may  be  selected ;  and  of  this  the  child  can  take  one 
tablespoonful  every  half-hour.  Milk,  however,  is  seldom 
found  to  agree ;  but  Diet  13  may  be  tried. 

DIET  IN  CHRONIC  VOMITING. 

In  this  disorder  the  food  must  be  given  in  minute 
quantities,  one  teaspoonful  in  many  cases  being  all  that 
can  be  retained  at  one  time.  This  may  be  repeated  every 
twenty  minutes.  In  bad  cases  milk  must  be  strictly  for- 
bidden. 

Choice  may  be  made  from  the  following  : — 

Diluted  whey  with  cream,  as  in  Diet  1. 
Yeal  broth  and  barley-water  (equal  parts). 
One  teaspoonful  of  Mellin's  food  for  infants  dis- 
solved in  four  ounces  of  whey  and  barley- 
water  (equal  parts),  or  in  equal  parts  of  weak 
veal  broth  and  barley-water. 
White  wine  whey  (see  page  113). 
Whatever  the  food  may  be,  it  should  be  given  cold,  not 
lukewarm. 

If  the  vomiting  be  only  occasional  and  not  severe.  Diet 
17  may  be  tried,  suiting  the  quantities  to  be  given  at  one 
time  to  the  degree  of  irritability  of  the  stomach.  Pan- 
creatised  milk  sometimes  is  well  borne  in  these  cases.  If 
the  infant  be  much  exhausted,  it  is  best  to  trust  solely  to 
white  wine  whey  given  cold,  and  in  small  quantities,  at 
regular  intervals. 

When  the  vomiting  has  ceased  the  infant  may  begin  to 


346 


DIET  IN  DISEASE 


take  regular  meals,  and  milk  can  be  returned  to  ;  but 
frequent  change  should  be  insisted  upon.  It  is  best  to 
order  three  foods  to  be  given  in  rotation  during  the  day, 
and  for  the  night  a  desiccated  milk  food,  such  as  Allen 
and  Hanbury's  No.  2  or  Nestle' s  food.    Thus  : — 

Diet  18. 

Benger's  food  with  cow's  milk. 
Savory  and  Moore's  food  with  milk. 
Mellin's  food  with  milk  and  barley-water  (equal 
parts) . 
To  be  given  in  rotation. 

Nestle' s  food  for  the  night,  if  required. 

See  also  Diets  2,  4,  5,  6,  and  16. 

DIET  IN  RICKETS. 

Here  the  kind  of  diet  will  depend  in  a  great  measure 
upon  the  condition  of  the  alimentary  canal.  In  almost 
all  cases  it  will  be  found  that  farinaceous  food  has  been 
supplied  in  excessive  quantities,  and  the  amount  will  have 
to  be  considerably  reduced.  If  the  bowels  are  relaxed, 
with  loose,  slimy,  offensive  motions.  Diets  15  and  16  will 
be  suitable.  If  the  motions  are  healthy,  Diets  5,  6,  7,  8, 
10,  11,  may  be  made  use  of,  according  to  the  age  of  the 
child. 

If  the  child  be  sixteen  or  eighteen  months  old  the 
following  is  of  service  : — 

Diet  19. 

First  meal,  7.30  a.m. 

A  tablespoonful  of  Mellin's  food  for  infants,  dis- 
solved in  a  teacupful  of  milk. 

Half  a  slice  of  stale  bread  soaked  in  liquid  bacon 
fat. 


DIET  IN  MUCOUS  DISEASE 


347 


Second  meal,  11  a.m. 

A  breakfast- cupful  of  milk  alkalinised  by  fifteen 
drops  of  the  saccharated  solution  of  lime. 

Third  meal,  2  p.m. 

A  good  tablespoonful  of  well-pounded  mutton 
chop  with  gravy,  and  a  little  crumbled  stale 
bread  or  a  rusk. 

Or  a  good  tablespoonful  of  the  flower  of  broccoli 

stewed  until  quite  tender. 
A  cupful  of  beef  tea  (one  pound  to  the  pint) . 
Thin  bread-and-butter. 
For  drink  toast-water. 

Fourth  meal,  6  p.m. 

A  tablespoonful  of  Mellin's  food,  dissolved  in  a 
breakfast-cupful  of  new  milk  ;  a  rusk. 

Or  (if  no  meat  has  been  given)  the  lightly  boiled 

yolk  of  one  egg. 
Thin  bread-and-butter. 
Milk  and  water. 

DIET  IN  MUCOUS  DISEASE. 
(Farinaceous  food  is  as  much  as  possible  to  be  avoided.) 

Diet  20. 

{For  a  child  ahotd  seven  years  of  age  and  upwards.) 

Breahfast,  8  a.m. 

Three  quarters  of  a  pint  of  fresh  milk  alkalinised 
by  twenty  drops  of  the  saccharated  solution  of 
lime. 

A  thin  slice  of  well-toasted  bread. 
Fresh  butter. 

A  fresh  egg,  lightly  boiled  or  poached. 


348 


DIET   IN  DISEASE 


Dinner,  noon. 

A  mutton  chop  without  fat,  broiled. 

Well-hoiled  cauliflower  or  French  beans,  according 

to  season. 
A  thin  slice  of  well- toasted  bread. 
Half  a  wine-glassful  of  Hoff's  extract  of  malt. 

Tea,  4  p.m. 

Milk  and  thin  bread-and-butter. 
Sardines,  or  a  little  boiled  fish. 

Supper,  7  P.M. 

A  breakfast- cupful  of  beef  tea  (a  pound  to  the  pint). 
A  thin  slice  of  dry  toast. 

Diet  21. 

(For  the  same.) 

Breakfast,  8  a.m. 

Half  a  pint  of  new  milk,  alkalinised  with  fifteen 

drops  of  the  saccharated  solution  of  lime. 
A  slice  of  cold  roast  beef  or  mutton. 
A  thin  slice  of  well-toasted  bread. 

Dinner,  noon. 

A  little  boiled   sole  or  turbot  (without  melted 

butter) . 
A  thin  slice  of  stale  bread. 

Chocolate  blanc-mange  (made  with  gelatine,  not 
cornflour) . 

A  sherry-glassful  of  light  claret,  diluted  with  an 
equal  bulk  of  water. 

Tea,  4  P.M. 

A  poached  egg  on  a  thin  slice  of  dry  toast. 
Milk  and  water. 


Supper,  7  P.M. 

Three-quarters  of  a  pint  of  alkalinised  new  milk. 


DIET  IN   PULMONARY  PHTHISIS 


349 


Diet  22. 
(For  the  same.) 

Breakfast,  8  a.m. 

One  teaspoonful  of  Cadbury's  cocoa  essence  boiled 

for  one  minute  in  half  a  pint  of  milk. 
A  slice  of  thin  dry  toast. 
A  thin  rasher  of  fat  bacon,  crisply  broiled. 

Dinner,  noon. 

The  wing  of  a  roasted  or  boiled  fowl. 
A  little  well-boiled  flower  of  cauliflower  or  well- 
stewed  celery. 
A  slice  of  thin  dry  toast  or  stale  bread. 
Baked  custard  pudding. 

Half  a  wine-glassful  of  HofE's  extract  of  malt. 

Tea,  4  p.m. 

Half  a  pint  of  alkalinised  milk. 
A  lightly  boiled  egg. 
'  A  thin  slice  of  dry  toast. 

Supjper,  7  p.m. 

A  breakfast-cupful  of  beef  tea  (a  pound  to  the 
pint). 

A  thin  slice  of  dry  toast. 

It  would  be  unnecessary  to  occupy  space  by  giving  more 
diets  of  the  same  kind.  The  above  will  serve  as  illustra- 
tions of  the  kind  of  food  to  be  recommended. 

Two  of  the  meals  should  always  consist  principally  of 
milk.  For  the  other  meals  selection  should  be  made  from 
the  following : — 

Meats  :—Eoast  or  boiled  beef ;  roast  or  boiled  mutton; 
roast  or  boiled  fowl  (without  sauces)  ;  roasted  pheasant, 
turkey,  lark,  snipe,  pigeon,  or  quail. 

Fish: — Boiled  cod,  turbot,  mackerel,  or  sole;  raw 
oysters;  bloater;  kippered  herring ;  sardines. 

Eggs  : — Boiled  or  poached. 


350 


DIET  IN  DISEASE 


Soup : — Clear  turtle  ;  beef  or  veal  tea. 

Vegetables: — Cauliflower;  turnip  greens;  asparagus; 
young  French  beans ;  Spanish  onion,  lettuce,  or  celery 
(stewed) . 

For  drink  : — Sound  claret  or  burgundy  diluted  with 
water ;  toast-water  ;  milk  and  water. 

DIET  IN  PULMONARY  PHTHISIS. 

In  pulmonary  phthisis  farinaceous  food,  and,  indeed,  all 
fat-forming  material,  is  of  value  ;  but  usually  the  capability 
of  digesting  this  food  is  not  very  great,  as  in  almost  all 
such  cases  there  is  a  tendency  to  acid  dyspepsia.  In 
arranging  the  diet,  therefore,  the  greatest  attention  must 
be  paid  to  the  capabilities  of  the  child,  so  that  no  more  be 
given  him  than  he  is  able  readily  to  digest. 

Diet  23. 

(For  a  child  of  seven  years  and  upwards.) 

Breahfast,  8  a.m. 

Half  a  pint  of  new  milk  alkalinised  with  fifteen 

drops  of  the  saccharated  solution  of  lime. 
A  lightly  boiled  egg. 
Thin  bread-and-butter. 

Dinner,  12  or  1  p.m. 

A  slice  of  roast  beef  or  mutton  with  gravy. 
A  mealy  potato  well  mashed. 
Custard  or  batter  pudding. 

For  drink,  an  ounce  of  sound  claret  diluted  with 
twice  its  bulk  of  water. 

Tea,  4  or  5  p.m. 

A  teaspoonful  of  chocolate  or  cocoa  boiled  with  half 

a  pint  of  milk. 
Thin  bread-and-butter  or  a  rusk. 


DIET  IN  PULMONARY  PHTHISIS 


351 


Supper,  7  or  8  P.M. 

Half  a  dozen  raw  oysters. 
Bread-and-butter. 

The  ordinary  cocoa  is  to  be  preferred  for  the  third  meal, 
if  it  can  be  digested.  If  it  seems  too  heavy,  cocoatina  may 
be  used  instead. 

Diet  24. 

{For  a  child  of  the  same  age.) 

BreaTcfast,  8  a.m. 

Alkalinised  new  milk,  as  much  as  desired. 

A  rusk,  or  bread-and-butter. 

A  rasher  of  broiled  bacon. 
Dinner,  12  or  1  p.m. 

A  slice  of  boiled  leg  of  mutton. 

A  well-boiled  carrot  or  turnip. 

A  spoonful  of  savoury  omelet. 

For  drink,  claret  and  water,  as  before. 
Tea,  4  or  5  p.m. 

Bread  and  milk. 
Supper,  7  or  8  p.m. 

A  small  basin  of  tapioca  soup  or  of  clear  turtle 
soup. 


Diet  25. 

.  {For  the  same  age.) 

Breakfast,  8  a.m. 

Bread  and  milk. 
Dinner,  12  or  1  p.m. 

Roast  or  boiled  fowl. 

A  mealy  potato. 

Chocolate  blanc- mange  (made  with  gelatine). 
Claret  and  water. 

For  dessert,  a  good  bunch  of  sweet  grapes. 


DIET  IN  DISEASE 


Tea,  4  or  5  p.m. 

A  lightly  boiled  egg. 
Thin  bread-and-butter. 
Half  a  pint  of  milk. 

Or,  the  egg  may  be  beaten  up  raw  with  the  milk. 

Supper,  7  or  8  p.m. 

A  basin  of  strong  beef  tea. 


INDEX. 


A. 

PAGE 

Abdomen,  large,  in  infants          .              .  .  .8 

„          „     causes  of            .             .  .  .8 

„          „                  in  rickets            .  .             ,  137 

„       tenderness  of,  in  ulceration  of  bowels  .             .  84 

Abdominal  bandage       .             .             .  .55,  86,  95 

„        disease,  cry  in            .             .  .  .7 

„        pain  may  prevent  sucking         .  .  .53 

Accumulation  of  flatus  in  belly     .             .  .  .8 

„             fsecal  matter      .             .  .  .8 

Acidity,  treatment  of    .             .             .  .  .58 

Acute  diarrhoea            .             .             .  .  .27 

„  „  treatment  of  .  .  ,  .64 
„          „       in  rickets            ....  139 

„          „           inherited  syphilis           .  .             .  207 

„     disease,  dangers  of            .             .  .  .3 

„          „     secondary             .             .  .  .3 

„     indigestion          .             .             .  .  .27 

„            „        treatment  of     .              .  .  .64 

Adenoid  growths,  a  cause  of  chest  distortion  .             .  130 

,,            hollow  breathing  .              .  275 

„              „            laryngismus  stridulus  .             .  141 

Advantage  of  early  suckling         .             .  .  .32 

Air,  change  of,  in  mucous  disease               .  .             .  226 

„          „            rickets             .              .  .             .  167 

„  „  pulmonary  phthisis  .  .  .  297 
Alcohol  in  mucous  disease            ....  220 

Alkalies,  their  value  in  artificial  feeding     .  .  .59 

,,  in  chronic  pulmonary  phthisis  .  .  .  304 
„       in  mucous  disease          ....  222 

23 


354 


INDEX 


PAGE 

Aloes  in  mucous  disease  ....  222 

Analysis  of  bone  in  rickets  .  .  .  .  151 

„        human  milk  ...  17,  20 

Anatomical  characters  of  tuberculous  glands  .  .  308 

„  chronic  intestinal  catarrh    .  .  80 

„  „  rickets  .  .  .  .  149 

Anthelmintics  .....  240 

Aphthse         .  .  .  .  .  .28 

an  obstacle  to  sucking     .  .  .  .53 

„       treatment  of    .  .  .  .  .  64 

Aperients  for  infants     .  .  .  .  .56 

Appetite  in  chronic  diarrhoea       .  .  .  .68 

„      pulmonary  phthisis       .  .  .  267 

„         mucous  disease  ....  221 

„         rickets        .....  135 

„         wasting  children        .  .  .  ^  .28 

Aromatics  in  the  treatment  of  infants'  complaints      .  .  59 

Articulations  in  rickets  .....  134 

"  Artificial  human  milk "  .  .  .  .36 

„       feeding         .  .  .  .  .34 

Ascaris  lumbricoides      .....  228 

„  „  a  cause  of  chronic  diarrhoea       .  .  79 

,,  „  admission  of,  into  body  .  .  231 

„  „  description  of  .  .  .  228 

„  ,,  migrations  of  .  .  .  237 

„  „  symptoms  produced  by  .  .  336 

„  „  treatment  of  ...  241 

Ascites,  a  cause  of  big  belly         .  .  .  .8 

„      causes  of  .  .  .  .  .8 

„      in  tuberculous  mesenteric  glands    .  .  .  321 

Ass's  milk      .  .  .  .  .  .44 

„        analysis  of    .  .  .  .  .44 

„        laxative  effect  of         .  .  .  .44 

Asthmatic  seizures  in  caseous  bronchial  glands  .  .  312 

Astringents  in  chronic  diarrhoea   .  .  .  .99 

„  ,,     pulmonary  phthisis  .  .  .  304 

Atrophy,  infantile         .  .  .  .  .16 

„  „       diagnosis  of      .  .  .  .  257 

Auscultation  of  chest  in  children  ....  275 

Auscultatory  signs  in  caseous  bronchial  glands  .  .  313 

„  „  fibroid  induration  of  lung         .  .  280 

„  „  pneumonic  phthisis    .  .  .  278 

„  „  tubercular  phthisis    .  .  .  277 


INDEX 


355 


B. 

PAGE 

Bacillus,  the  tubercle     .....  249 

Baked  flour     .  .  .  .  .  .49 

Bandage,  flannel,  to  belly  .  .  .55,  86,  95,  167 

Barley-water,  preparation  of        .  .  .  .37 

„         usefulness  of  .  .  .       37,  39,  113 

Bath,  cold      .  .  .  .  .  .13 

„       „    danger  of,  in  phthisis  ....  299 

„     hot       .  .  .  .  .  .13 

,,     mercurial  .....  205 

„     mustard  .  .  .  .  .13 

„     warm,  for  constipation        ,        .     .  .  .58 

„  „       colic     .  .  .  .  .62 

„       convulsions         .  .  .  .62 

Belladonna,  its  effect  in  arresting  perspirations  .  .  171 

Belly,  large,  causes  of    .  .  .  .  .8 

,,        „     in  rickets  .....  137 

„        „         weakly  babies       .  .  .  .8 

Bending  of  ribs  in  rickets  ....  128 

Benger's  food  .  .  .  .  .40 

Bilious  attacks  in  mucous  disease  ....  214 

Bismuth  in  chronic  diarrhoea        .  .  .  .98 

Blisters  for  caseous  bronchial  glands  .  .  .  329 

„     inadmissible  for  infants   .  .  .  .12 

Blood  in  sputum  .....  267 

stools  .  .  .  .  .69 

Blowing  breathing,  value  of         .  .  .  .  275 

Bone,  analysis  of,  in  rickets         ....  151 

„    arrest  of  growth  of,  in  rickets  .  .  .  134 

,,    caries  of,  a  cause  of  phthisis  .  .  .  295 

„     deformities  of,  in  rickets     .  .  .  .123 

„    syphilitic  disease  of  ...  .  183 

Bones,  flat,  in  rickets,  changes  in  .  .  .  .  150 

„     of  face,  arrest  of  development  of      .  .  .  124 

„         skull,  ossification  of,  in  rickets     .  .  .  151 

„  ,,  „  syphilis    .  .  183,  190 

,,     reconsolidation  of,  in  rickets  .  .  .  151 

Bothriocephalus  latus    .....  230 

„  ,,    description  of  .  .  .  230 

„  „    treatment  for  .  .  .  244 

Bowels,  tuberculous  ulceration  of  .  .  .81 

Brain,  enlargement  of,  in  rickets  .  .  .  155 


INDEX 


Breast,  pigeon,  in  consumptive  children 

PAGE 

.  264 

„        „  rickets 

128 

„    refusal  of 

52 

Breast-milk,  analysis  of . 

17,  20 

„         differences  in 

17 

Breathing,  bronchial,  in  phthi 

sis  . 

„        cavernous,  value  of  . 

.  277 

„         harsh,  in  phthisis 

.  275 

„         in  tuberculous  bronchial  glands  . 

312 

„             pulmonary  pht 

lisis 

„         weak,  in  phthisis 

.  277 

Bridge  of  the  nose  flattened  in  inherited  syphilis 

.  180 

Bronchi,  dilated,  diagnosis  of 

.  289 

signs  of 

Bronchial  glands,  tuberculous 

.  309 

>j                sj  y> 

altered  voice  from 

.  312 

>}                         3>  )3 

asthma  from  . 

oU 

j»  5> 

auscultatory  signs  of 

.  313 

)>  >y 

blistering  for 

))                j>  J> 

cough,  character  of 

312 

i>                }j  jj 

diagnosis  of  . 

314 

yy                 3y  >J 

douche,  tepid,  in  treatment  of 

.  327 

yy                 yy  » 

engorgement  of  veins  from 

.  311 

yy                yy  yy 

epistaxis  from 

.  311 

yy                yy  yy 

haemoptysis  from 

.  311 

yy                 yy  yy 

hoarse  voice  from 

Q1  9 
ol^ 

yy                 yy  yy 

pressure  on  nerves  from 

oil 

yy                 yy  yy 

„          trachea  from 

.  312 

yy                yy  yy 

„          veins  from  . 

.  311 

yy                yy  yy 

rupture  of  vessels  in 

.  311 

yy                yy  >y 

symptoms  of  . 

.  310 

yy                yy  yy 

termination  of 

yy                 yy  J> 

venous  hum  from 

.  315 

Bronchitis,  an  obstacle  to  sucking 

.  52 

„        in  rickets 

.  138 

Buttocks,  rash  on,  in  inherited  syphilis 

.  180 

c. 

Calomel  for  chronic  vomiting       ....  117 
„        inherited  syphilis       ....  204 
Carpo-pedal  contractions  in  rickets  .  .  .  141 

Casein  of  cow's  milk,  coagulability  of         .  ,  20,  30 


INDEX 


357 


PAGE 

Casein  of  human  milk,  coagulability  of       .  .  '  .20 

Catarrh  in  rickets         .    •         .  .  .  .  138 

„  „       danger  of        .  .  .  .  138 

„  „       treatment  of   .  .  .  .  171 

„     of  bowels         .  .  .  .  .66 

„  stomach        .....  105 

Causation  of  chronic  diarrhoea      .  .  .  .76 

„  „       pulmonary  phthisis     .  .  .  262 

„  „      vomiting      ....  108 

infantile  atrophy      .  .  .  .17 

„  large  belly  in  infants  .  .  .7 

„  mucous  disease        ....  216 

„  refusal  of  breast       .  .  .  .52 

„  rickets      .  .  .  .  .  160 

Cavernous  breathing,  value  of      .  .  .  .  277 

Cavities  in  lung,  diagnosis  of        .  .  .  .  289 

Cerebral  disease,  cry  in  .  .  .  .7 

,,       sinuses,  thrombosis  of     .  .  .  .71 

Cestode  worms  .....  227 

Change  of  air  in  phthisis  ....  297 

„  „  mucous  disease  ....  226 
„         „       rickets  ....  167 

Changes,  morbid,  in  bones  in  rickets  .  .  124,  150 

Chapman's  flour  .  .  .  .  .48 

Characters,  anatomical,  of  chronic  intestinal  catarrh  .  .  80 

„  „  rickets  .  .  .  149 

Chest,  deformed,  in  consumptive  children  .  .  264 

„  ,,  rickets  ....  128 

„     examination  of,  in  children  .  ,  .  273 

„     expander,  the      ,  .  .  .  .  296 

„     shape  of,  in  consumptive  children     .  .  .  264 

„     small,  in  phthisis  ....  264 

Chronic  diarrhoea  .  .  .  .  .66 

„  „        abdominal  pain  in  .  .  .67 

„  „        appetite  in        .  .  .  .67 

„  „        bad  feeding  a  cause  of     .  .  .77 

„  „        blood  in  stools  in  .  .  .69 

„  causation  of     .  .  .  .76 

,,  „        complications  of  .  .  .70 

„  „        convulsions  in  .  .  .  .70 

M  J,        counter-irritation  in        .  .  .95 

„  „        dentition  in      ,  .  .  .73 

„        diet  in  .  .  .  .90 


INDEX 


PAGE 

Chronic  diarrhoea,  diagnosis  of      .             .  .  .82 

,,          „        mode  of  death  in         ,    .  .  .72 

„          „        morbid  anatomy  of          .  .  .80 

„  „        nitrate  of  silver  for         .  .        *     .  99 

„          „        oedema  in         .             .  ,  ,  70 

„          „        pneumonia  in    .             .  .  .70 

„          „        prevention  of    .             .  .  .85 

„          „        prognosis  in      .              .  .  .85 

„        raw  meat  in      .              .  .  .  100 

„          „        serous  effusions  in           .  .  .70 

„          „        stimulants  in     .              .  .  .  100 

„          „        stools,  characters  of        .  .  .68 

„          „        thrombosis  of  cerebral  sinuses     ,    .  .71 

„          „        tongue  in         .             .  .  68,  72 

„          ,y        tonics  in           .             .  .  .  101 

„          „        treatment  of     .             .  .  .88 

„          „        ulceration  of  bowels  in     .  .  .80 

„      hydrocephalus  in  rickets  .              .  .  .  125 

„      interstitial  keratitis  in  inherited  syphilis  .  .  187 
„      intestinal  catarrh.    See  Chronic  diarrhoBa. 
„      pulmonary  phthisis.    See  Phthisis, 

„      vomiting  .....  125 

„                   arsenic  in         .             .  .  .  116 

„          „        causation  of      .              .  .  .  108 

„          „        diagnosis  of      .              .  .  .  110 

„          „        diet  in             .              .  .  .  Ill 

„          „        emetics  in        .             .  ,  .  117 

„          „        modes  of  death  in           .  .  .  107 

„        spurious  hydrocephalus  in  .  .  107 

„          „        stimulants  in     .             .  .  .  117 

„          „        warmth,  importance  of,  in  .  .  110 

„          „        white  wine  whey  in         .  .  .  113 

Cicatrices,  linear,  in  inherited  syphilis        .  .  182, 196 

Cirrhosis  of  lung.    See  Fibroid  induration. 

Clavicle,  deformity  of,  in  rickets  ....  130 

Cleanliness  of  feeding-bottles,  necessity  of  .  .  .  43,47 

Cleft  palate  an  obstacle  to  sucking             .  .  .53 

„        feeding-bottle  for      .             .  .  .53 

Climate,  change  of,  in  mucous  disease         .  .  .  226 

„            „             phthisis     .             .  .  .297 
„            rickets       ....  107 

Colic,  treatment  of       .             .             .  .  .62 

Colour  of  face  in  chronic  bowel  complaint    .  .  6,  67,  72 


INDEX  359 

PAGE 

Colour  of  face  in  exhaustion         .  .  .  .6 

„  „       indigestion        .  .  .  .6 

„  „        inherited  syphilis  .  ,  .  182 

„  „       mucous  disease  ....  213 

Coma  from  over-dose  of  santonine  .  .  .  242 

Condensed  milk  .  .  .  .  .45 

„  „     inefficiency  of,  after  second  month    .  .  45 

Consolidation  of  bone  in  rickets  ....  152 
Constipation  in  infants,  cause  of   .  .  .  .24 

„  „      treatment  of  .  .  .56 

Convulsions,  reflex,  rare  in  wasted  infants   .  .  .4 

„         from  indigestion       .  .  .  .  4, 63 

„  „  „        treatment  of  .  .  .63 

„  fj    worms  ....  236 

„  in  rickets  .....  140 
„  „       treatment  ....  174 

Corrosive  sublimate  in  inherited  syphilis     .  .  .  203 

Coryza  syphilitica         .  .  .  .  .  179 

Cough  from  cheesy  bronchial  glands  .  .  .  312 

„        „    fibroid  induration  of  lung        .  .  .  272 

„  in  pulmonary  phthisis  ....  265 
Counter-irritants  .  .  .  .  .12 

„  in  chronic  diarrhoea         .  .  .95 

„  disease  of  bronchial  glands         .  .  329 

„  pulmonary  phthisis       .  .  .  305 

„  precautions  in  using  .  .  12 

Cow's  milk,  analysis  of  .  .  .  .  20, 44 

„         artificially  digested    .  .  .  .45 

,,         indigestibility  of       .  .  .  .43 

„         preparation  of,  for  infants        .  .  37, 45 

Cowhage  for  worms  .....  243 
Cracked- pot  percussion  note  ....  275 
Cracks  on  skin  in  inherited  syphilis  .  .  .  182 

Cranio-tabes  in  rickets  .....  126 
„  syphilis  .....  196 

Cream  in  artificial  feeding  .  .  .  .50 

Creasote,  value  of,  in  phthisis  ....  301 
Cry  of  infants,  characters  of        .  .  .  .7 

„   in  inherited  syphilis,  quality  of  .  .  .  182 

Curvature  of  spine  in  rickets  ....  127 
Cysticercus  cellulosse     .....  232 


360  INDEX 


PAGE 

Debility  of  stomach  a  cause  of  vomiting      .  .    •         .  117 

Decay  of  teeth  in  rickets  ....  127 

Deformities  of  bone  in  rickets       .  .  .  .  123 

chest      .  .  .  .  .128 

clavicle  .....  130 
„  femur     .....  132 

humerus .  .  .  .  .  130 

„  pelvis     .....  131 

„  radius  and  ulna     .  .  .  .  .  130 

scapula  .....  131 
skull      .  .  .  .  .125 

„  spine      .....  127 

tibia       .  .  .  .  .132 

Delayed  symptoms  in  inherited  syphilis       .  .  .  186 

Dentition,  care  required  during    .  .  .  .88 

„        in  chronic  diarrhoea     .  .  .  .73 

inherited  syphilis     ....  183 
rickets      .....  127 
„        progress  of,  no  guide  to  weaning  .  .51 

Derangement,  digestive,  accompanying  worms  .  .  283 

„        in  mucous  disease  .  .  .  215 

rickets  .  .  122,136 

Description  of  worms  .....  227 
Development  of  tsenia  .....  232 
Diagnosis  of  chronic  diarrhoea      .  .  .  .82 

„  „      vomiting      .  .  .  .  110 

„  dilated  bronchi         ....  289 

„  enlarged  bronchial  glands        .  .  .  314 

„  fibroid  induration  of  lung        .  .  .  287 

„     phthisis         ....  289 
„  inherited  syphilis      ....  194 

„  mucous  disease         ....  218 

„  pneumonic  phthisis  ....  284 

„  rickets       .....  156 

,,  tubercular  phthisis   ....  282 

„  tabes  mesenterica     .  .  .  .  322 

„  ulcerated  bowels       .  .  .  .84 

„  worms       .....  238 

Diarrhoea,  acute  .  .  .  .  .27 

,,  „     treatment  of       .  .  .  .64 

„  „    in  rickets  ....  139 


INDEX 


361 


PAGE 

Diarrhoea,  acute,  in  rickets,  treatment  of     .             .  .  172 
„        chronic.    See  Chronic  diarrhoea. 

„        lienteric        .             .             .             .  .76 

„           „       character  of  stools        .             .  .76 

„            „       nature  of       .              .             .  .76 

„            „       symptoms  of  .              .              .  .76 

„            „       treatment  of  .             .             .  .  103 

Diet  after  weaning       .             .             .             .  .54 

„   general  directions  on            .             .             .  .10 

„  in  chronic  diarrhoea              .             .             .  90, 342 

„           „      vomiting              .             .             .  Ill,  345 

„       infantile  atrophy              ...  34,  340 

„       mucous  disease  ....  219,  347 

phthisis            ....  299,  350 

rickets              ....  166,  346 

„  of  wet-nurse          .             .             .             .  .31 

Dietaries        ......  331 

Dilated  bronchi,  diagnosis  of        ,             .              .  .  289 

Discharge  from  nose  in  inherited  syphilis     .              .  .  179 

Diseased  bone,  early  removal  of    .             .             .  .  295 

„           in  inherited  syphilis             .              .  .  183 

Displacement  of  liver  and  spleen  ...  8,  137 

Douche,  tepid,  in  treatment  of  tuberculous  glands      .  .  327 

Drilling,  use  of,  in  expanding  chest            .             .  .  296 

Dulness  on  percussion,  value  of     .             .              .  .273 

Dumb-bells,  use  of        .             .             .              .  .  296 

Dyspnoea  in  enlarged  bronchial  glands        .             .  .  312 

E. 

Early  symptoms  of  rickets           .             .             .  .  120 

Ecthyma,  syphilitic        ....  .  181 

Effusions,  serous,  in  chronic  diarrhoea          .             ,  .70 

Elastic  bandage  to  loose  joints     .              .             .  .170 

„     tissue  in  sputum              .             .             .  .  289 

Emaciation  in  chronic  diarrhoea  .  .  .  .67 
„  „  phthisis  ....  268 
„               „       vomiting  ....  106 

„            mucous  disease     ...             .  .  214 
„             rickets   .....  136 
Emphysema  in  rickets    .....  152 

Empyema,  diagnosis  of  .             .             .             .  .  288 

Enema,  astringent        .             .             .             .  .99 


INDEX 


PAGE 

Enema  for  constipation               .             .  ,  .57 

„     in  diagnosis  of  faecal  accumulations  ,  ,  323 

Enlargement  of  liver  in  rickets    .             .  .  137,  153 

lymphatic  glands               .  .  153,  308 

„            mesenteric  glands             .  .  .  319 

„            spleen  in  rickets  .             .  .  137,  153 

„  „  inherited  syphilis .  .  .  194 
Epilepsy  as  a  sequel  of  rickets     ....  142 

Epistaxis  from  caseous  bronchial  glands      .  .  .  311 

Eruptions  on  skin  from  indigestion             .  .  .25 

„          „       in  inherited  syphilis        .  .  .  180 

Examination  of  belly  in  mesenteric  disease  .  .  320 

„           chest  in  children               .  .  .  273 

„           liver  and  spleen  .             .  .  .9 

„           stools  in  cases  of  wasting  .  .  22,  69,  257 

Exhaustion,  signs  of,  in  infants    .              .  .  .7 

Expectorants,  value  of  .             .             .  .  .  303 

Expectoration,  rarity  of,  in  young  children  .  .  .  266 

Expression  of  infants,  importance  of  noting  .  .  5 
„        in  rickets    .....  136 

External  applications    .             .              .  .  .10 

„               in  chronic  diarrhoea   .  .  .95 

„                     ,,        vomiting  .  .  .  118 

Eyelids,  lividity  of        ,              .             .  .  .6 

E. 

Face,  colour  of            .             .             .  .  .6 

„           in  inherited  syphilis            .             .  7,  182 

Faecal  accumulations,  diagnosis  of              .  .  .  323 

Farinaceous  foods         .             .             .  .  .48 

„             injurious  in  mucous  disease  .  .  219 

Fat,  percentage  of,  in  breast-milk               .  .  17,  20 

„             „          cows'  milk  .              .              .  .20 

Feeding,  artificial         .             .             .             .  .34 

Feeding-bottle             .             .             .             .  .43 

„          cleanliness  of        .              .             .  43, 47 

,,  for  cleft  palate  .  .  .  .53 
Feet,  cold,  a  cause  of  catarrh       ....  167 

griping  pain  .  .  .61 
Femur,  deformity  of,  in  rickets  ....  132 
Fibroid  induration  of  lung           ....  263 

„           „        causes  of        .             .             .  •  263 


INDEX 


363 


PAGE 

Fibroid  induration,  cough  in         .  .  .  .  272 

„  „        diagnosis  of    .  .  .  .  289 

„  „        dilated  bronchi  in  .  .  272, 289 

„  „        expectoration  in  .  .  ,  272 

„  „        symptoms  of  .  .  .  .  271 

„  „        treatment  of  .  .  .  .  305 

„      phthisis,  diagnosis  of       .  .  .  .  290 

,,  ,,       sputum  in  .  .  .  .  289 

Fits,  "inward''  .  .  .  .  .27 

„       screaming,  in  infants         .  .  .  .25 

„  „    ^   soothing  effect  of  friction  in  .  .61 

Flannel  bandage  to  belly  .  .  .  55,  86,  95,  167 

„  „       in  rickets  ....  167 

Flat  bones,  changes  in,  in  rickets  .  .  .  .150 

Flatulence      .  .  .  .  .  .24 

„        treatment  of.  .  .  .  .59 

Flatus  a  cause  of  big  belly  .  .  .  .8 

Flour,  baked,  mode  of  preparing  .  .  .  .49 

Fontanelle,  importance  of  examining  .  ,  .7 

„         in  chronic  hydrocephalus  .  .  .  125 

„  exhaustion  .  .  .  .7 

„  inherited  syphilis  ....  183 

„  rickets    .....  125 

Food,  Melliu's,  for  infants  .  .  .  .40 

„     improper,  cause  of  diarrhoea  .  .  .77 

„  „  „       rickets  ....  163 

„  „  „       vomiting  .  .  .  108 

Frequency  of  suckling   .  ,  .  .  .33 

Fresh  air  in  the  treatment  of  mucous  disease  .  .  226 

„  „  phthisis         .  .  .  298 

„  „  rickets  .  .  .  167 

Frictions       .  ,  .  .  .  .10 

„       for  constipation  .  .  .  .58 

„  rickets    .....  171 

screaming  fits        .  .  .  .61 

„       mercurial      .....  204 

oily  .  .  .  .  .10 

G. 

Genal  line      .             ,             .  .  .  .6 

General  management  of  infants    .  .  *  .55 

Genito-crural  nerve,  stimulation  of  .  .  .4 


INDEX 


PAGE 

Glands,  bronchial,  tuberculosis  of  .             .             .  .  309 

„      cervical,  enlarged  in  inherited  syphilis           .  .  184 

„     lymphatic,  tuberculosis  of              .              .  .  307 

„     mesenteric,  tuberculosis  of             .              .  .  319 

Goat's  milk    .             .             .             .             .  .44 

„       „    analysis  of  .              .              .              .  .44 

Good  figure,  best  mode  of  forming              .              .  .  294 
Grey  powder  in  inherited  syphilis  ....  203 

Griping  from  cold  feet  .              .              .              .  .  61 

„      pain,  treatment  of          .              .              .  .61 

Growth  of  bone,  arrest  of,  in  rickets  .  .  .  133 
Gymnastic  exercises      .....  296 

H. 

Habitual  constipation    .              .             .              .  24, 56 

Haemoptysis  in  diseased  bronchial  glands     .              .  .311 

„         rarity  of,  in  children               .              .  .  266 

Hair,  fall  of,  in  inherited  syphilis               .              .  .  182 

„    growth  of,  in  scrofulous  children       .              .  .  252 

Hand-feeding  of  infants              .              .              .  .34 

Hardening  system,  the  .              .              .              .  .  295 

Harsh  respiration  .....  275 

Heart,  displacement  of,  in  fibroid  induration  of  lung  .  .  280 

Hoarse  voice  in  diseased  bronchial  glands    .              .  .  312 

„        „       infants  .             .              .              .  .7 

„  inherited  syphilis  ....  194 

Hot  bath       .             .             .             .             .  .12 

„       in  colic          .             .              .              .  .62 

„           constipation            .             .             .  .56 

„           convulsions              .              .              .  .62 

„       method  of  giving          .              .  ,           .  .13 

Humerus,  deformity  of  .              .              .              .  .  130 

Hunger,  sign  of,  in  infants          .              .              .  .33 

Hydrocephalus,  chronic,  in  rickets              .              .  .  142 
„            spurious              ....  107 

„                „       treatment  of        .             .  .  118 

I. 

Improper  food  a  cause  of  chronic  diarrhoea               .  .  77 

„       vomiting               .  .  108 

„                          rickets               .              .  .  163 


INDEX 


366 


PAGE 

Incontinence  of  urine  in  mucous  disease      .  .             .  211 

Increased  peristaltic  action  of  bowels          .  .  .75 

Indigestibility  of  cow's  milk       .             .  .  .21 

Indigestion,  acute         .             .             .  .  .27 

„          „     treatment  of     .             .  .  .64 

Infantile  atrophy         .             .             .  .  .16 

„          „       causation  of      .             .  .  .17 

„          „       symptoms  of     .             .  .  .22 

„          „       treatment  of     .             .  .  .30 

Infants,  examination  of  cliest  in  .              .  .  .273 

„       general  management  of  .              .  .  .55 

„       hand-feeding  of             .             .  .  .34 

„  secondary  diseases  in  wasting  .  .  .3 
Influence  of  soils  on  phthisis  ....  297 
Inherited  syphilis         .....  177 

„          „       appearance  of  first  symptoms  .  .177 

„                  chronic  interstitial  keratitis  .              .  186 

„          „       complexion  in  .             .  .             .  182 

„                  coryza  in         .             .  .             .  179 

cry  in              .              .  .              .  182 

„          „       delayed  symptoms      ,     .  .              .  186 

„       dentition  in      .             .  .              .  183 

„           „       diagnosis  of      .              .  .              .  194 

diet  in             .             .  .  .205 

„          „       disease  of  bone              .  .              .  188 

„         liver.             .  .  .192 

„          „            „         spleen             .  .             .  194 

„            „         thymus           .  .              .  177 
„          „       ecthyma          ....  181 

„           „       erythema         .              .  .   ,           .  180 

fall  of  hair  in  .              .  .  .182 

,,          „       fontanelle  in    ,             .  .             .  183 

„          „       infection  after  birth       .  .             .  178 

„                  influence  of  parents  on   .  .             .  197 

„          „       local  applications            .  .              .  208 

„                   local  peritonitis  in           .  .              .  193 

„          „       mercurial  baths              .  .             .  205 

„          „             „      inunctions        .  .             .  204 

„          „       mucous  patches             .  .             .  181 

„          „            „         „        treatment  of  .             .  208 

,,  „  necrosis  of  nasal  bones  .  .  .  180 
„  „  nodes  ....  184 
„          „       notched  teeth   ....  186 


INDEX 


PAGE 

Inherited  syphilis,  paralysis  in      .             .  .  .  186 

„          „       prevention  of    .              .  .  .  202 

„          „       prognosis  in     .             .  .  .  200 

„          3,       relapses  in       .              .  .  ,  187 
„       skin  eruptions  ....  180 

„          „       splenic  enlargement  in    .  .  .  184 

„                  symptoms  of    .              .  .  .  177 

tonics  in          .              .  .  .  209 

„          ,y       treatment  of    .              .  .  .  202 

„          „       ulcerations  in   .             ,  .  .  181 

„          „       vomiting  in      .             .  .  201,  207 

„           „       wasting  in        .              .  .  .  202 

Injections  in  chronic  diarrhoea      .              .  .  .99 

Innominate  vein,  pressure  on        .              .  .  311,  316 

Inoculation  of  syphilis  .  .  ^  .  .  200 
Intellect  in  rickets        .....  137 

Internal  remedies,  general  remarks             .  .  .15 

Intestinal  catarrh          .              .              .  .  .66 

"  Inward  fits "              .              .              .  .  .27 

Iodide  of  iron  in  inherited  s^'philis             .  .  .  209 

„        „       disease  of  bronchial  glands  .  .  328 

J. 

Jadelot's  lines  .  .  .  .  .5 

Joints,  diseased,  in  inherited  syphilis  .  .  ,  183 

„  loose,  in  rickets  .....  134 
Jugular  vein,  distended  in  disease  of  bronchial  glands  .  311 

K. 

Kamala  for  tape-worms  .....  245 
Keratitis,  chronic,  interstitial       ....  186 

L. 

Labial  line      .  .  .  .  .  .6 

Large  belly  in  rickets    .....  137 

,,       „        weakly  children      .  .  .  .8 

Laryngeal  sounds,  conduction  of  .  .  .  .  276 

Laryngismus  stridulus  in  rickets  ....  140 

„  „  „        treatment  of  .  .  175 

Laryngitis,  cry  in         .  .  .  .  .7 


INDEX 


367 


Late  talking  in  rickets  .....  137 
walking  in  rickets.  ....  135 

Lateral  curvature  of  spine  in  rickets  .  .  .  127 

Ligaments,  relaxation  of,  in  rickets  .  .  .  135 

Lime,  hypophosphite  of,  in  phthisis  .  .  .  304 

Lime-water  to  dilute  cow's  milk   .  .  .  .37 

Linear  cicatrices  .....  182 

Lips,  lividity  of  .  .  .  .  .6 

Lithotomy  in  rickety  children  ....  131 
Liver  disease  in  inherited  syphilis ....  192 

„    enlarged,  a  cause  of  big  belly  .  .  .8 

„       in  rickets  .  .  .  137, 153 

„     mode  of  examining  .  .  .  .9 

Local  peritonitis  in  inherited  syphilis  .  .  .  193 

Looseness  of  joints  in  rickets  ....  134 
Lungs,  examination  of,  in  infants  ....  273 
Lymphatic  glands,  enlarged,  in  rickets        .  .  .  154 

„  „      tuberculosis  of  .  .  .  307 


M. 


Malformation  of  permanent  teeth  . 

Malt,  value  of. 

Malted  foods  . 

Massage,  value  of 

Maternal  suckling 

Measles  a  cause  of  refusal  of  breast 

Meat  for  young  children 

„    raw,  for  chronic  diarrhoea 
Medicated  milk  in  treatment  of  syphilis 
Mellin's  food  . 

Mercurial  treatment  of  inherited  syphilis 
Mesenteric  disease,  infrequency  of 
„         glands,  tuberculosis  of. 
Method  of  hand-rearing  of  infants 
Migration  of  worms 
Miliaria  from  sweating  . 
Milk,  abundant,  behaviour  of  child  when 
"  artificial  human 
ass's 

condensed 

cow's,  sometimes  indigestible 
goat's  . 


368 


INDEX 


Milk,  human  and  cow's  milk  compared 

„    medicated,  in  treatment  of  inherited  syphilis 
„    of  syphilitic  mothers 
„  pancreatised 
Mobility  of  joints  in  rickets 
Motionless  belly  in  respiration 
Movement  of  nares  in  respiration  . 
Mucous  disease 

„  diagnosis  of 

„  diet  in  . 

„  symptoms  of 

„  treatment  of 

Mucous  patches 

„  treatment  of 

Muscles,  voluntary,  in  rickets 
Mustard  bath  .... 

„  for  chronic  diarrhoea 

„  chronic  vomiting  . 


N. 

Nares,  movement  of,  in  respiration 
Nasal  bones,  necrosis  of  . 

„     furrow  .... 

„     obstruction  a  cause  of  refusal  of  breast 
Nematode  worms 
Nervous  sensibility  diminished 
Nettlerash  a  sign  of  indigestion  . 
Nipple,  retraction  of,  an  obstacle  to  suckling 
Nitrate  of  silver  in  chronic  diarrhoea 
Nodes  in  inherited  syphilis 
Notching  of  permanent  teeth 
Nurse,  test  of  a  good 


O. 

Oculo-zygomatic  furrow 

(Edema  of  face  in  caseous  bronchial  glands  . 
„        feet  and  hands  in  chronic  diarrhoea 
„        lower  limbs  in  mesenteric  disease 

Oil  of  male  fern  for  tape- worm 

„     use  of,  for  external  application 

Opium  a  cause  of  vomiting 


PAGE 

20 
203 
203 
46 
134 
7 
7 

210 
218 
219 
210 
219 
181 
208 
155 
13 
95 
118 


7 

.  180 
6 

53,  202 
.  227 
3 

.  25 
.  52 
.  99 
.  184 
.  186 
.  17 


6 

.  311 

.  70 

.  321 

.  244 

.  11 

.  110 


INDEX  369 

PAGE 

Ossification  of  bone  in  rickets  ....  149 
Otitis  in  infantile  atrophy  .  .  .  .29 

Over-feeding  of  infants .  .  .  .  .18 

Oxyuris  vermicularis     .....  227 
„  „  treatment  for  .  .  .  240 

P. 

Pain  shown  by  expression  of  face  .  .  ,  .6 

„    in  belly  .             .             .  .  .  .5 

„        chest  .             .              .  .  .  .5 

„        head  .             .              .  .  .  .5 

Pancreatised  foods        .             .  .  .  .45 

Papain,  value  of            .             .  .  .  .97 

Parasitic  stomatitis       .             .  .  .  .26 

„           „         treatment  of .  .  .  .64 

Patches,  mucous  .....  181 

„          „      treatment  of      .  .  .  .  208 

Pelvis,  arrest  of  growth  of,  in  rickets  .  .  .  131 

„     deformity  of,  in  rickets     .  .  .  131, 158 

Pepsine,  value  of          .             .  .  .  .97 

Peptonised  milk            .             .  .  .  .45 

Percussion,  importance  of  two  fingers  in  .  .  .  273 
Perforation  of  septum  nasi           ....  180 

Pericardium,  white  patch  on        .  .  .  .  153 

Peristaltic  action  of  bowels  increased  .  .  .75 

Peritonitis  complicating  mesenteric  disease  .  .  321,324 
„        in  inherited  syphilis     ....  193 

Perspirations  in  rickets  .              .  .  .  .  .  121 

Pertussis  a  cause  of  mucous  disease  .  .  .  216 

Perverted  ossification  of  rickety  bone  .  .  .  148 

Phthisis,  fibroid            .             .  .  .  .290 

„          „      diagnosis  of        .  .  .  .  290 

„       pneumonic      .....  270 

„             „         diagnosis  of  .  '  .  .  .  284 

„             „         physical  signs  of  .  .  .278 

„             „         symptoms  of .  .  .  .  270 

„             „         treatment  of .  .  .  .  296 

„       tubercular  chronic  primary  .  .  .  269 

„             „         causation  of  .  .  .  .  261 

„             „         diagnosis  of  .  .  .  .  282 

„             „         pathology  of .  .  .  .  261 


24 


INDEX 


PAGE 

Phthisis,  tubercular  chronic  primary,  physical  signs  of  .  277 

„  „  symptoms  of.  .  .  .  269 

Pigeon-breast  in  phthisis  ....  264 

„        ,y  rickets  ....  128 

Pneumonia  a  cause  of  refusal  of  breast        .  .  .53 

„        in  chronic  diarrhoea     .  .  .  .70 

„        without  symptoms      .  .  .  .4 

Poisoning  by  santonine  .....  242 
Pomegranate  bark  for  tape-worm  ....  245 
Pony  exercise  for  phthisical  children  .  .  .  298 

Precautions  against  cold  ...  89,  167 

Premature  weaning  sometimes  necessary     .  .  .52 

Preparations  of  mercury  for  treatment  of  inherited  syphilis      .  203 
Pressure  on  nerves  of  chest         ....  311 
„        superior  vena  cava     ....  311 
„        trachea      .....  312 
„        veins  of  abdomen      ....  321 
Prevention  of  chronic  diarrhoea   .  .  .  .85 

„  phthisis  .....  293 

.,  rickets    .....  164 

„  transmission  of  syphilis       .  .  .  202 

Prognosis  in  caseous  bronchial  glands         .  ,  .  318 

„  „       mesenteric  glands        .  .  .  325 

„        chronic  diarrhoea      .  .  .  .85 

„  inherited  s^^philis  ....  200 
,,  pulmonary  phthisis  ....  290 
„        rickets     .  .  .  .  .  159 

Prolapsus  ani,  treatment  of  .  .  .  .  247 

Proteids,  percentage  of,  in  breast-milk        .  .  17,  31 

Pulmonary  phthisis — see  FMMsis. 

Purgative  enemata       .  .  .  .  .57 

R. 

Radius  and  ulna,  deformities  of    .  .  .  »  .  130 

Raw  meat  for  chronic  diarrhoea    ....  100 

Reconsolidation  of  bone  in  rickets  .  .  .  145 

Recovery  from  chronic  diarrhoea  .  .  .  .73 

„  rickets  .....  145 

Red  gum        .  .  .  .  .  .25 

Reflex  convulsions        .  .  .  .  .4 

„  „  rare  in  cachectic  infants  .  .  4 

Refusal  of  breast  by  infants        .  .  .  .52 


INDEX 


371 


■  PAGE 

Relapses  in  chonic  diarrhoea         ....  102 

„        inherited  syphilis       .  .  .  .  187 

Relaxation  of  ligaments  in  rickets  .  .  .  135 

Respiration,  harsh        .....  275 

„         in  rickets  ....  129,  139 

„  pulmonary  phthisis  .  .  .  275 

„         weak        .....  275 

Retraction  of  nipple     .  .  .  .  .52 

Rhubarb  in  treatment  of  acidity  .  .  .  .58 

Rickets         .  .  .  .  .  .120 

„     analysis  of  bone  in  .  .  .  .  151 

„     arrest  of  growth  of  bone  in  .  .  .  133 

„     catarrh  and  bronchitis  in  .  .  .  .  138 

„     causes  of  .  .  .  .  .  160 

„      chronic  hydrocephalus  in  ...  142 

„      climate  for       .....  167 

„     collapse  of  lung  in  .  .  .  .  152 

„     complications  of  ...  .  138 

„      convulsions  in  .  .  .  .  .  140 

„      deformities  of  bone  in     .  .  .  .  123 

„     diagnosis  of      .  .  .  .  .  156 

„     diarrhoea  in      .  .  .  .  .  139 

„     diet  in  ....  .  166 

„     enlargement  of  ends  of  bones         .  .  12^,  134 

„  „  liver  and  spleen      .  .  .  153 

„     epilepsy  as  a  sequel  of     .  .  .  .  142 

„     general  symptoms  of        .  .  .  121,  135 

„     general  tenderness  in       .  .  .  .  121 

„      intellect  in       .  .  .  .  .  137 

„      laryngismus  stridulus  in  .  .  .  .  140 

„     lithotomy  in     .  .  .  .  .  131 

„     loose  joints  in    .  .  .  .  .  135 

„     mode  of  death  in  ...  .  145 

„     morbid  changes  in  bones  .  .  .  123,  149 

„     ossification  of  bone  in      .  .  .  .  149 

„     pathology  of     .  .  .  .  .  149 

„     pigeon-breast  in  ....  128 

„     prevention  of    .  .  .  .  .  164 

„     prognosis  in      .  .  .  .  .  159 

„     scurvy  in  .....  143 

skull  in  .  .  .  .  .124 

„     softening  of  bones  in       .  .  .  .  123 

„     spinal  curvature  in  .  .  .  .  127 


372 


INDEX 


Rickets,  splints,  value  of 

„     sweating  in 

talking  late  in  . 

„      teething  in 

„     tonics,  time  of  giving 

„      treatment  of 

„  walking  late  in  . 
Rules  for  choosing  nurse 


.  170 
.  121 
.  137 

126,  145 
.  168 
.  165 

135, 157 
.  17 


S. 

Saliva,  time  of  first  secretion  of  .  .  .  .  38 

Salts,  their  value  in  nutrition       .  .  .  .19 

Santonine  in  treatment  of  worms  ....  241 
„       poisonous  effects  of       .  .  .  .  242 

Scaly  eruption  in  inherited  syphilis  .  .  .  180 

Scapula,  deformity  of,  in  rickets  ....  131 
Schneiderian  membrane,  mucous  patches  on  .  .  180 

Screaming  fits  in  children  .  .  .  .25 

„  treatment  of       .  .  .61 

Scrofulous  diathesis,  type  of        .  .  .  .  252 

,,       pneumonia — See  Pneumonic  phthisis. 
Scurvy,  complicating  rickets        ....  143 
„  „  „      treatment  of   .  .  .  176 

„      during  treatment  of  chronic  diarrhoea  .  .  94 

Sea-air  in  rickets  .....  167 

Second  dentition  a  cause  of  mucous  disease  .  .  .  217 

Secondary  acute  diseases  in  wasted  children  .  .  5 

Septum  nasi,  perforation  of  .  .  .  .  180 

Serous  effusions  in  chronic  diarrhoea  .  .  .70 

Shampooing,  value  of    .  .  .  .  .14 

,,  in  rickets  .  .  .  .  .171 

Shape  of  chest  in  phthisical  children  .  .  .  264 

,,  „       rickets  ....  128 

Sign  of  hunger  in  infants  .  .  .  .33 

Silver,  nitrate  of,  in  chronic  diarrhoea  .  .  .99 

Size  of  liver,  to  estimate  .  .  .  .9 

,,        spleen  .  .  .  .  .9 

Skin,  tint  of,  in  chronic  diarrhoea  .  .  67,  72 

„         „         inherited  syphilis  .  .  .  182 

„        ,,        mucous  disease    ....  213 
Skull,  shape  of,  in  hydrocephalus  ....  125 
„        „  rickets  ....  125 


INDEX 


873 


PAGE 

Slimy  tongue  in  mucous  disease   ....  211 

Snuffling  in  syphilis       ....  179,  195 

Soils,  influence  of,  on  phthisis       ....  295 

Somnambulism  in  mucous  disease .  .  .  .  211 

Spasmodic  cough  in  pulmonary  cirrhosis     .  .  .  272 

Spine,  deformities  of,  in  rickets    ....  127 

Spleen,  enlargement  of,  in  inherited  syphilis  .  184,  194 

„  „  rickets  .  .  .  137 

„      method  of  examining       .  .  .  .9 

Spurious  hydrocephalus .....  107 

„  „  treatment  of  .  .  .  118 

Sputum,  elastic  tissue  in  ...  •  289 

Stethoscope,  use  of,  in  examining  infants    .  .  .  275 

Stethoscopic  signs  in  pulmonary  phthisis     .  .  .  275 

Stimulants     .  .  .  .  .  .15 

„        indications  for  giving  .  .  .  .7 

Stomach,  irritability  of,  in  inherited  syphilis  .  204,  207 

Stools,  blood  in  .  .  .  .  .69 

„     character  of,  in  chronic  diarrhoea     .  .  67,  69 

„     examination  of,  in  cases  of  wasting  .  .       22,  69,  257 

"  Strippings " .  .  .  .  .  .45 

Strophulus  a  sign  of  indigestion  .  .  .  .26 

Suckling,  first  time  of  .  .  .  .  .32 

„       frequency  of  .  .  .  .  .32 

„       obstacles  to   .  .  .  .  .52 

Sugar,  its  use  in  nutrition  .  .  .  .19 

Supra-spinous  fossa,  blowing  breathing  at    .         _     .  .  283 

Symptoms  of  chronic  diarrhoea     .  .  .  .67 

„  „      phthisis      ....  265 

„  „      vomiting    ....  105 

„  infantile  atrophy    .  .  .  .22 

„  inherited  syphilis    ....  177 

„  mucous  disease       ....  210 

„  rickets     .....  121 

„  worms     .....  233 

Syphilis  and  rickets,  connection  between      .  .  .  164 

„      inherited — see  Inherited  syjphilis. 

„      miscarriage  a  result  of    .  .  .  177,  196 

„      secretion  of  milk  in        .  .  .  .  203 

System,  the  hardening  .....  295 


374 


INDEX 


T. 

PAGE 

Tabes  mesenterica,  abdomen  in     .  .  .  .  320 

„  ascites  in        .  .  .  .  321 

„  „         cramps  of  limbs  in        .  .  ,  321 

„  „        diagnosis  of    .  .  .  .  322 

„  „         prognosis  in    .  .  .  .  325 

„  „         symptoms  of  .  .  .  .  319 

„  „        treatment  of    .  .  .  .  329 

Taenia  medio-canellata  .....  230 

„    solium  .  .  .  .  .  .  229 

„        „     treatment  for         ....  244 

Talking,  late  in  rickets  .....  137 

Tears,  a  favourable  sign  in  chronic  diarrhoea  .  .  85 

Teeth,  care  required  during  cutting  of        .  .  .  88 

„     early  decay  of,  in  rickets    ....  127 

„     late  appearance  of,  in  rickets  .  .  .  126 

„     malformation  of  permanent  .  .  .  186 

Teething  in  chronic  diarrhoea        .  .  .  .73 

„  inherited  syphilis       .  .  .  .183 

„  rickets        .  .  .  .  .  127 

Temperature  in  chronic  diarrhoea  .  .  .  .69 

„  „        vomiting ....  107 

fibroid  lung         .  .  .  .  272 

„  pneumonic  phthisis  .  .  .270 

„  tubercular  phthisis  .  .  .  269 

Tenderness,  general,  in  rickets      ....  121 

„        of  belly  in  tabes  mesenterica     .  .  .  321 

„  ,,      ulceration  of  bowels  .  .  84 

Test  of  a  good  nurse      .  .  .  .  .17 

Thigh  bone,  deformities  of,  in  rickets         .  .  .  132 

Thorax,  shape  of,  in  phthisical  children       .  .  .  264 

„  „         rickets  .  .  .  .  128 

Thrombosis  of  cerebral  sinuses      .  .  .  .71 

Thrush  .  .  .  .  .  .26 

,,     a  cause  of  refusal  of  breast  .  .  .53 

„     treatment  of      .  .  .  .  .64 

„     value  of,  in  prognosis        .  .  .  .26 

Thymus  gland,  disease  of  ...  .  177 

Tibia,  deformity  of,  in  rickets      ....  132 

Tint  of  skin,  in  chronic  diarrhoea  .  .  .6,  67,  72 

„         „  inherited  syphilis  .  .  .  182 

„  mucous  disease    ....  213 


INDEX 


376 


PAGE 

Tissue,  elastic,  in  sputum  ....  289 

Tongue  in  acute  indigestion         .  .  .  .28 

„  chronic  diarrhoea         ...  68,  72 

chronic  vomiting         ....  106 

„         mucous  disease  .  .  .  .  211 

„  spurious  hydrocephalus  .  .  .  107 

Tongue-tie,  an  obstacle  to  sucking  .  .  .53 

„         rarity  of  true  .  .  .  .53 

Tonics  .  .  .  .  .  .15 

„     in  inherited  syphilis         ....  209 

„         mucous  disc  ise  ....  225 

„         rickets         .....  168 

Trachea,  pressure  on     .  .  .  .  .  312 

Treatment,  general,  of  wasting    .  .  .  .10 

„         of  acidity  of  stomach  .  .  .  .58 

„  aphthae    .  .  .  .  .64 

„  chronic  diarrhoea    .  ,  .  .88 

„  „      pulmonary  phthisis   .  .  .  296 

«  M      vomiting    .  .  .  .110 

„  colic  in  infants       .  .  .62 

constipation  in  infants  .  .  .56 

convulsions  from  indigestion  .  .  .63 

„  „  in  rickets  .  .  .174 

„  diarrhoea  in  inherited  syphilis  .  .  207 

„  „  rickets ....  172 

„  fibroid  lung  ....  305 

„  infantile  atrophy     .  .  .  .30 

„  inherited  syphilis   ....  202 

„  laryngismus  stridulus  .  .  .  I75 

„  mucous  disease       ....  219 

«  patches      ....  208 

„  prolapsus  ani         ....  247 

„  rickets     .  .  .  .  ,  165 

scurvy     .  .  .  .  .176 

„  spurious  hydrocephalus         .  .  .118 

„  thrush      .  .  .  .  .64 

„  vomiting  in  syphilis  .  .  ,  207 

„  „  gastric  catarrh   .  .  .  no 

„  worms     .....  240 

Tricocephalus  dispar     .....  228 

Tubercle  bacillus  ....  249,  261 

Tubercular  phthisis — see  Phthisis. 

Tuberculosis  secondary  to  pneumonic  phthisis  .    263,  270,  285 


376 


INDEX 


PAGE 

Tuberculosis  secondary  to  rickets  ....  145 
Tuberculous  ulceration  of  bowels  .  .  .  81,  83 

Turpentine  in  treatment  of  convulsions        .  .  .63 

M  tape-worm         .  .  .  246 

Type  of  scrofulous  diathesis         .  .  •.  .  252 

„       tuberculous  diathesis        ....  252 

U. 

Ulceration  of  bowels,  diagnosis  of .             .  .  .  84 

„                „       symptoms  of             .  .  .84 

„               „       tuberculous .              .  .  .81 

„             nasal  mucous  membrane        .  .  .  180 

Ulcerations,  linear,  in  inherited  syphilis       .  .  .  184 

Unsuitable  food  a  cause  of  chronic  diarrhoea  .  .  77 

„                 99                 99      vomiting  .  .  108 

„                 „             infantile  atrophy  .  .  16 

„                 „             rickets             .  ,  .  163 

Urine,  incontinence  of,  in  mucous  disease  .  .  .211 
,,      in  rickets            .....  155 

Urticaria,  a  sign  of  indigestion     .              .  .  .25 

y. 

Vaccination  an  importer  of  syphilis  .  .  .  200 

Value  of  aromatics  for  infants      .  .  .  .59 

Vein,  portal,  pressure  on  .  .  .  .  321 

Veins,  pressure  on,  in  tabes  mesenterica      .  .  .  321 

Vena  cava,  superior,  pressure  on   .  .  .  .  316 

,,    innominata,  left,  pressure  on  .  .  311,  316 

Vermifuges     ......  240 

Venous  engorgement  of  face  and  neck         .  .  .  311 

Vocal  vibration  in  infants  ....  273 

Voluntary  muscles  in  rickets        ....  155 

Vomiting,  chronic — see  Chronic  vomiting. 

„        danger  of,  in  inherited  syphilis   .  .  .  201 

,,        in  acute  indigestion      .  .  .  .27 

„  „  „       treatment  of  .  .  .64 

„        in  inherited  syphilis        .  .  .  201,  207 

,,  „     treatment  of  .  .  207 


W. 

Walking,  lateness  of,  in  rickets  . 
Warm  baths  for  constipation 


135,  157 
.  58 


INDEX 


377 


PAGE 

Warmth  in  chronic  diarrhoea        .  .  .  .89 

„  „      .  vomiting       ....  110 

„  inherited  syphilis       .  .  .  .  206 

„  phthisis       .....  295 

rickets        .....  167 

Wasting,  causes  of        .  .  .  .  .2 

from  over-feeding         .  .  .  .21 

from  vomiting  ....  106 

in  chronic  diarrhoea       .  .  .  .68 

„  „       phthisis         ....  268 

„  mucous  disease         ....  214 

,,  rickets      .....  136 

Weak  respiration,  value  of  .  .  .  .  275 

Weaning,  dentition  no  guide  to    .  .  .  .51 

„       diet  after      .  .  .  .  .54 

„       method  of     .  .  .  .  .52 

„       time  of  .  .  .  .  .51 

Wet-nurse,  diet  of         .  .  .  .  .31 

„         rules  for  choosing      .  .  .  .17 

„         test  of  a  good  .  .  .  .30 

Whey,  use  of,  in  hand-feeding      .  .      91,  112,  331,  343,  345 

„     white  wine         .....  113 

Whitlow  in  inherited  syphilis       ....  182 

Whooping-cough  a  cause  of  mucous  disease .  .  .  216 

Wind-pipe,  lumbricus  in  ...  .  237 

Woman's  milk,  analysis  of  .  .  .  .20 

„         „     coagulability  of   .  .  .  .20 

„         „      difference  from  cow's  milk  .  .  .20 

,,         ,,     variations  in       .  .  .  .17 

Worms  ......  227 

„       appearance  of  tongue  in  .  .  .  .  235 

„      cestode  .....  227 

„       diagnosis  of      .  .  .  .  .  238 

„      nematode         .....  227 

„      symptoms  of    .  .       ,      .  .  .  233 

,,      treatment  of     .  .  .  .  .  240 

„      varieties  of       .  .  .  .  .  227 


PRINTED  BY  ADLAED  AND  SON, 
BARTHOLOMEW  CLOSE;,  E.G.,  AND  20,  HANOVER  SQUARE,  W. 

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